18 Jan 2023 Lyn Mary BRIND · Prevention of Future Deaths report Norfolk
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Concerns raised 2 Failure to maintain Emergency Department capacity for safe ambulance-to-hospital transfer View source Failure to discharge medically fit patients when suitable community beds are unavailable View source
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Lyn Mary BRIND · 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
Lyn Mary Brind attended her GP on 24 May 2022 and was taken to Queen Elizabeth Hospital, where she waited on an ambulance and had elevated NEWS2 observations. Her oxygen requirement increased without escalation, and no further physiological observations or ECG were undertaken before she deteriorated and died from cardiac failure. The report identified delays in transfer, monitoring, escalation and senior medical assessment, alongside wider overcrowding and bed-capacity pressures at the hospital.
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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 maintain Emergency Department capacity for safe ambulance-to-hospital transfer
Wider context from the report “6) Evidence was heard that there are regularly too many patients in the Emergency Department and so ambulances cannot safely transport patients into the Emergency Department . The EEAST is working with the Hospital (along with other hospitals in the area) to find ways to deal with this problem and methods are in place to try to alleviate the consequences of these delays.
7) However, it was heard that this is a much wider and more complex problem, in that the Hospital is unable to discharge patients who are medically fit to be discharged and they remain occupying much needed beds. This in turn means patients cannot be moved from the Emergency Department into the hospital wards, and patients remain waiting in ambulances. This in turn causes delays in ambulances being returned to normal duty and being able to attend to emergencies in the community.
8) Evidence was heard that at the time of Mrs Brind's death, approximately 7 ambulances were waiting to transfer patients into the Emergency Department, Queen Elizabeth Hospital . At the time of the inquest, this had risen to 17 ambulances commonly waiting to transfer patients from the ambulance into the Emergency Department .
7) Further at the time of the inquest there were approximately 140 beds at the Queen Elizabeth Hospital occupied by patients who were medically fit to be discharged, but beds could not be found in the community
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to discharge medically fit patients when suitable community beds are unavailable
Wider context from the report “6) Evidence was heard that there are regularly too many patients in the Emergency Department and so ambulances cannot safely transport patients into the Emergency Department. The EEAST is working with the Hospital (along with other hospitals in the area) to find ways to deal with this problem and methods are in place to try to alleviate the consequences of these delays.
7) However, it was heard that this is a much wider and more complex problem, in that the Hospital is unable to discharge patients who are medically fit to be discharged and they remain occupying much needed beds . This in turn means patients cannot be moved from the Emergency Department into the hospital wards, and patients remain waiting in ambulances. This in turn causes delays in ambulances being returned to normal duty and being able to attend to emergencies in the community.
8) Evidence was heard that at the time of Mrs Brind's death, approximately 7 ambulances were waiting to transfer patients into the Emergency Department, Queen Elizabeth Hospital. At the time of the inquest, this had risen to 17 ambulances commonly waiting to transfer patients from the ambulance into the Emergency Department.
7) Further at the time of the inquest there were approximately 140 beds at the Queen Elizabeth Hospital occupied by patients who were medically fit to be discharged, but beds could not be found in the community
” 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 additional staffed hospital-bed capacity through 2024–25.
Verbatim wording from the response “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.” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the plan’s measures to improve urgent-care waiting times and ambulance response times.
Verbatim wording from the response “I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times, including to improve A&E wait times to 78% of patients being admitted, transferred, or discharged within four hours by March 2025. The plan also commits to reducing average 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
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver 5,000 additional staffed, permanent hospital beds compared with 2022–23 plans.
Verbatim wording from the response “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.” 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 Invest an additional £1 billion through the Discharge Fund to support timely hospital discharge.
Verbatim wording from the response “We are also investing an additional £1 billion this year through the Discharge Fund, to support the NHS and local authorities to ensure timely and effective discharge from hospital. This funding follows £600 million last year and £500 million in 2022/23. The NHS and local authorities are using this funding to help provide people with the right care in the right place when they are discharged from hospital. We have also ensured every acute hospital has access to a care transfer hub, bringing together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support with a view to promoting early planning and timely discharge. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances 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 Ensure every acute hospital has access to a care transfer hub for complex discharges.
Verbatim wording from the response “We are also investing an additional £1 billion this year through the Discharge Fund, to support the NHS and local authorities to ensure timely and effective discharge from hospital. This funding follows £600 million last year and £500 million in 2022/23. The NHS and local authorities are using this funding to help provide people with the right care in the right place when they are discharged from hospital. We have also ensured every acute hospital has access to a care transfer hub, bringing together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support with a view to promoting early planning and timely discharge. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads.” Source location Response from Department of Health and Social Care
Open published response
11 Jan 2023 Leroy Patrick HAMILTON · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 6 Lack of inpatient mental health beds View source Lack of an agreed multi-agency protocol for informal patients absconding from emergency departments View source Failure to undertake and appropriately classify risk assessments for missing persons View source Failure to classify reported people as missing persons View source Failure to provide continuous specialist care, support or observation for acutely ill mental health patients awaiting a bed View source Lack of Psychiatric decisions unit spaces View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Leroy Patrick HAMILTON · 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
Leroy Patrick HAMILTON, who had psychosis and depression, left hospital emergency departments while awaiting mental health assessment and was later found deceased in a river on 6 December 2021. The inquest concluded that he drowned whilst suffering an acute psychotic relapse. Concerns included shortages of inpatient mental health beds and psychiatric decision unit spaces, the lack of a safe space for acutely ill patients, and failures to classify and risk-assess him as a missing person.
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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 Lack of inpatient mental health beds
Wider context from the report “1. Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces: The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU. Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy 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 Lack of an agreed multi-agency protocol for informal patients absconding from emergency departments
Wider context from the report “3. Multi agency protocol for informal missing patients: The inquest heard how there is no agreed protocol to deal with informal patients who abscond from emergency departments . Consideration should be given to setting up an agreed protocol so that all agencies involved understand their respective roles and responsibilities.
” 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 and appropriately classify risk assessments for missing persons
Wider context from the report “5. WMP risk assessments for missing persons: When Mr Hamilton was first reported as missing no risk assessment was undertaken about his level of risk to himself . The call had confirmed he was at risk of harming himself . The leads to a concern that staff do not understand when and how to risk assesses incidents and when to identify high risk incidents .
” 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 classify reported people as missing persons
Wider context from the report “4. WMP Missing person investigations: The inquest heard how on 2 occasions (03/12/21 and 07/12/21) there was a failure to treat Mr Hamilton as a missing person when he was reported as missing . On both occasions he should have been treated as a high risk missing person. This raises a serious concern that staff do not understand when people should be classified as missing . Consideration should be given to ensuring staff properly understand how to assess if someone should be treated as a missing person and WMP should consider whether further training is required.
” 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 continuous specialist care, support or observation for acutely ill mental health patients awaiting a bed
Wider context from the report “2. Safe space: The inquest heard how it is often the case that due to the lack of inpatient beds and PDU spaces patients are often left in the Emergency department unattended or sent home with periodic reviews by the home treatment team whilst waiting for a bed . This means that acutely ill mental health patients are often left for long periods without any specialist care, support or observation . Consideration should be given to setting up a safe space where patients can wait for a bed or PDU space which is able to cater for their special needs and keep them safe.
” 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 Psychiatric decisions unit spaces
Wider context from the report “1. Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces : The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU . Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments.
” 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 Support faster hospital discharge to reduce bed occupancy and A&E waiting times.
Verbatim wording from the response “Regarding the lack of inpatient mental health beds and psychiatric decisions unit (PDU) spaces and the availability of ‘safe space’, we are supporting the NHS to take action to reduce waiting times in A&E, including through adding 5,000 more permanent general and acute beds, speeding up hospital discharge and increasing transparency and the available information on waiting times and the NHS’s progress in reducing them.” 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 funding to support adult social care and NHS discharges, including from mental health inpatient settings.
Verbatim wording from the response “To support adult social care and discharges across the NHS, including from mental health inpatient settings, up to £2.8 billion was made available in 2023/24 and £4.7 billion in 2024/25, with the aim of reducing bed occupancy.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand adult community mental health services to support patients in the community and reduce reliance on inpatient treatment.
Verbatim wording from the response “More widely, through the NHS Long Term Plan, we have invested almost £1 billion extra in community mental health care for adults by March 2024, expanding community mental health services, so that patients are supported to stay well in their communities. This major expansion in funding for community mental health services commenced in all areas in 2021/22 and one of its aims is to reduce reliance on inpatient treatment.” Source location Response from Department of Health and Social Care
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and publish statutory guidance for discharge from mental health inpatient settings.
Verbatim wording from the response “The Department has also worked with NHS England and other system partners to develop statutory guidance for discharge from all mental health inpatient settings, which was” 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 West Midlands Police is addressing the multi-agency protocol for informal patients who abscond from emergency departments.
Verbatim wording from the response “Turning to the matter of a multi-agency protocol to deal with informal patients who abscond from emergency departments. The WMP have addressed this in their response as they are currently setting up a working group with key partner agencies, including mental health agencies and professionals, to discuss and design a joint missing person protocol. They anticipate that these discussions will take into account the circumstances of Mr Hamilton's case.” 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 Local policing arrangements are outside the Health Minister’s remit.
Verbatim wording from the response “The report raises concerns over numbers of inpatient mental health and psychiatric decision unit beds and arrangements for informal missing patients. It also raises concerns about local policing arrangements and you will understand that these are outside of my remit as a Health Minister.” Source location Response from Department of Health and Social Care
Open published response
21 Nov 2022 Celia Lindsey MARSH · Prevention of Future Deaths report Avon
View report summary
Concerns raised 12 Potentially unsafe exposure to undeclared allergens for people at significantly higher risk of fatal reactions View source Potentially misleading food-labelling wording and public understanding of allergen absence View source Lack of a robust system for capturing and recording anaphylaxis cases View source Failure to obtain and preserve stomach contents and tissue samples at post-mortem examination View source Lack of adequate education for doctors and patients in anaphylaxis risk groups View source Delays in raising suspected anaphylaxis deaths with the Senior Coroner View source Lack of robust confirmation of allergen absence in ingredients and production View source Outdated pathology guidance for suspected anaphylaxis deaths View source Lack of a standard protocol for timely and appropriate sampling in suspected anaphylaxis deaths View source Failure to retain hospital blood samples in suspected anaphylaxis cases View source Failure to prioritise post-mortem examinations in suspected anaphylaxis deaths View source Failure to obtain and store an early post-death blood sample for later analysis View source See 9 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
Celia Lindsey MARSH · 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
Celia Lindsey Marsh died on 27 December 2017 after suffering fatal anaphylaxis caused by milk protein in a wrap she believed was safe to eat. The principal concerns included the investigation and retention of evidence in suspected anaphylaxis deaths, education for doctors and patients, systems for reporting anaphylaxis, and potentially misleading “dairy-free” and other allergen-labelling claims.
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 Potentially unsafe exposure to undeclared allergens for people at significantly higher risk of fatal reactions
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group .
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Potentially misleading food-labelling wording and public understanding of allergen absence
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” 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 robust system for capturing and recording anaphylaxis cases
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis , to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and preserve stomach contents and tissue samples at post-mortem examination
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” 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 adequate education for doctors and patients in anaphylaxis risk groups
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” 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 raising suspected anaphylaxis deaths with the Senior Coroner
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” 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 robust confirmation of allergen absence in ingredients and production
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim .
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” 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 Outdated pathology guidance for suspected anaphylaxis deaths
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old , the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” 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 standard protocol for timely and appropriate sampling in suspected anaphylaxis deaths
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” 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 retain hospital blood samples in suspected anaphylaxis cases
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise post-mortem examinations in suspected anaphylaxis deaths
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and store an early post-death blood sample for later analysis
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Open source report
16 Nov 2022 Awaab Ishak · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 6 Failure to rectify recognised disrepair without waiting for claimant agreement View source Lack of consideration of damp and mould in housing standards guidance View source Lack of easily accessible up-to-date health information on damp and mould risks View source Failure of the damp and mould HHSRS risk assessment data to reflect current known health risks View source Lack of private landlord sector access to independent Housing Ombudsman complaint investigation View source Lack of guidance on adequate property ventilation View source See 3 more concerns
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AI-generated summary
Awaab Ishak · 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
Awaab Ishak died on 21 December 2020 at the Royal Oldham Hospital, aged two, following a severe respiratory condition associated with prolonged exposure to mould in his home. The report identifies concerns about inadequate guidance and risk assessment for damp and mould, limited access to up-to-date health information, delays in addressing recognised disrepair where legal claims were ongoing, and the lack of independent complaints investigation for private landlords.
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 rectify recognised disrepair without waiting for claimant agreement
Wider context from the report “4. The evidence highlighted a “policy” amongst the housing associations , in cases where a disrepair claim has been brought of waiting for agreement from the claimant (or their legal representative) before rectifying any recognised disrepair .
” 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 consideration of damp and mould in housing standards guidance
Wider context from the report “1. The 2006 document, “A Decent Home: Definition and Guidance for Implementation” does not give any consideration to the issue of damp and mould . Nor does it provide any guidance as to the need for a property to be adequately ventilated.
” 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 easily accessible up-to-date health information on damp and mould risks
Wider context from the report “3. There was no evidence that up to date relevant health information pertaining to the risks of damp and mould was easily accessible to the housing sector .
” 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 damp and mould HHSRS risk assessment data to reflect current known health risks
Wider context from the report “2. The HHSRS data sheet relating to damp and mould, is used to calculate risks of the incident and the spread of harm is not reflective of the current known risks of damp and mould and harm to health .
” 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 private landlord sector access to independent Housing Ombudsman complaint investigation
Wider context from the report “5. The private landlord sector does not have access to the Housing Ombudsman for their complaints to be investigated independently .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on adequate property ventilation
Wider context from the report “1. The 2006 document, “A Decent Home: Definition and Guidance for Implementation” does not give any consideration to the issue of damp and mould. Nor does it provide any guidance as to the need for a property to be adequately ventilated .
” 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 Commit to bringing forward legislation for a Private Rented Sector Landlord Ombudsman.
Verbatim wording from the response “The Government announced plans to introduce a new Private Rented Sector Landlord Ombudsman in the A Fairer Private Rented Sector White Paper.⁹ The proposal is for all private landlords in England to be required to be members of this Ombudsman. This will ensure that all tenants, regardless of whether they rent socially or privately, have access to redress where they have a legitimate complaint about their home.” Source location Response from Secretary of State for Levelling Up, Housing and Communities and Department for 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 Review and modernise the Housing Health and Safety Rating System, including damp and mould risk estimates, guidance and health-effect information.
Verbatim wording from the response “We agree this is a matter of concern. Our current review of the housing health and safety rating system (“HHSRS”) will support a better understanding of the known risks of damp and mould to health.” Source location Response from Secretary of State for Levelling Up, Housing and Communities and Department for 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 Disseminate the new damp and mould guidance to social housing providers, local authorities, landlords and tenants in accessible formats.
Verbatim wording from the response “Once completed, I (Secretary of State for Levelling Up, Housing and Communities) will write to social housing providers and local authorities to highlight the new guidance. I (Secretary of State for Levelling Up, Housing and Communities) will also make sure that it is available for landlords and tenants, working closely with stakeholders to ensure it is widely available, including in the future ensuring this is accessible for private landlords via the Privately Rented Property Portal.” Source location Response from Secretary of State for Levelling Up, Housing and Communities and Department for 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 reviewing the Decent Homes Standard, including ventilation and potential changes to its criteria.
Verbatim wording from the response “We agree this is a matter of concern. Damp and mould can have a serious impact on the health of tenants, and it is unacceptable for anyone to have to live in such conditions. While the requirement to deal with them is implicit in the current Decent Homes Standard (“DHS”), it is clear that the review of the standards which is currently underway is necessary.” Source location Response from Secretary of State for Levelling Up, Housing and Communities and Department for 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 Review existing guidance and develop and publish consolidated health guidance on damp and mould for the housing sector.
Verbatim wording from the response “The Department of Health and Social Care (DHSC), with the Department for Levelling Up, Housing and Communities (DLUHC), will lead a rapid review of existing guidance on the health impacts of damp and mould in homes, and then – engaging widely with interested parties – develop new consolidated guidance tailored to the housing sector. We will publish this new guidance by the summer. DHSC will lead this process and contribute expertise on the relevant health impacts, working closely with the UK Health Security Agency (“UKHSA”). DLUHC will contribute its expertise on the needs of the housing sector and how best to disseminate guidance to housing providers and tenants.” Source location Response from Secretary of State for Levelling Up, Housing and Communities and Department for 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 Housing associations, rather than Government, control dispute policies and must address delays in rectifying recognised disrepair.
Verbatim wording from the response “We agree this is a matter of concern. While the policies which Housing Associations set for disputes are not of course controlled by the Government, the ‘policy’ highlighted in Awaab Ishak’s case as a matter of concern is wrong. In Awaab Ishak’s case, the legal proceedings by Awaab’s family with respect to mould led to the landlord slowing down its response to the disrepair.” Source location Response from Secretary of State for Levelling Up, Housing and Communities and Department for Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The HHSRS review did not include updating the range of harms associated with damp and mould because that issue was outside its scope.
Verbatim wording from the response “The HHSRS review follows an initial scoping exercise that concluded in 2019, where landlords, tenants, agents, local authorities and academics told us they appreciated the link the HHSRS makes between housing and health and how it allows individual properties to be assessed on their merits, but that they found it complicated and inefficient to use. Ministers decided that work should be undertaken to clarify and modernise the HHSRS assessment and consider whether some hazard profiles could be removed or combined and to improve the guidance given to landlords and tenants.” Source location Response from Secretary of State for Levelling Up, Housing and Communities and Department for Health and Social Care
Open published response
Concerns raised 8 Lack of guidance on additional water-safety measures for augmented-care patients View source Risk of death from M abscessus infection among hospital patients, especially those who are immunosuppressed View source Lack of guidance requiring routine testing for mycobacteria and defining acceptable levels View source Heightened risk from M abscessus in new hospitals View source Continuing hospital water-associated transmission of M abscessus View source Incomplete understanding of M abscessus entry into and colonisation of hospital water systems View source Lack of guidance on identification and control of M abscessus in hospital water systems View source Failure of hospital water-safety guidance to align with British Standard BS 8580-2:2022 View source See 5 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
Karen Lesley Starling and Anne Edith Martinez · 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
Karen Lesley Starling and Anne Edith Martinez underwent lung transplant procedures at the new Royal Papworth Hospital and subsequently contracted hospital-acquired M abscessus infections, in consequence of which they died. The report identifies concerns that existing hospital water-system guidance provided no relevant guidance on mycobacteria or M abscessus, did not require routine testing or specify acceptable levels, and did not address additional measures for immunosuppressed patients or the risks associated with new hospitals.
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 guidance on additional water-safety measures for augmented-care patients
Wider context from the report “3. Health Technical Memorandum 04-01 Safe Water in Healthcare Premises was published by the Department of Health in 2016. It is concerned with the design, installation, commissioning and operation of hospital water systems. This guidance requires urgent review and amendment, whether by way of an Addendum or otherwise because:
a. It is a key document for hospital estate managers and Water Safety Groups;
b. It purports to provide comprehensive guidance on waterborne bacteria;
c. However, it provides no relevant guidance in relation to mycobacteria and none in relation to M abscessus. It provides no guidance on the identification and control of M abscessus. It does not require routine testing for mycobacteria, including M abscessus or provide guidance on acceptable levels (if any). Compliance with the guidance does not identify or guard against the risk from M abscessus;
d. It provides no guidance on any additional measures that may be required in respect of “augmented care” patients, including those who are immunosuppressed ;
e. It is not in any event consistent with British Standard BS 8580-2:2022 on Water Safety.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Risk of death from M abscessus infection among hospital patients, especially those who are immunosuppressed
Wider context from the report “1. It is recognised that M abscessus poses a risk of death to those who are immunosuppressed . That will be so for many patients at specialist hospitals such as Royal Papworth and more generally for hospital patients . To date, 34 patients at Royal Papworth have contracted M abscessus from the hospital’s water. Cases continue to be reported, albeit at a declining rate;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance requiring routine testing for mycobacteria and defining acceptable levels
Wider context from the report “3. Health Technical Memorandum 04-01 Safe Water in Healthcare Premises was published by the Department of Health in 2016. It is concerned with the design, installation, commissioning and operation of hospital water systems. This guidance requires urgent review and amendment, whether by way of an Addendum or otherwise because:
a. It is a key document for hospital estate managers and Water Safety Groups;
b. It purports to provide comprehensive guidance on waterborne bacteria;
c. However, it provides no relevant guidance in relation to mycobacteria and none in relation to M abscessus. It provides no guidance on the identification and control of M abscessus. It does not require routine testing for mycobacteria, including M abscessus or provide guidance on acceptable levels (if any) . Compliance with the guidance does not identify or guard against the risk from M abscessus;
d. It provides no guidance on any additional measures that may be required in respect of “augmented care” patients, including those who are immunosuppressed;
e. It is not in any event consistent with British Standard BS 8580-2:2022 on Water Safety.
” 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 Heightened risk from M abscessus in new hospitals
Wider context from the report “4. There is evidence that the risk from M abscessus is especially acute for new hospitals . Consideration needs to be given to whether special or additional measures are required in respect of the design, installation, commissioning and operation of hospital water system in new hospitals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Continuing hospital water-associated transmission of M abscessus
Wider context from the report “1. It is recognised that M abscessus poses a risk of death to those who are immunosuppressed. That will be so for many patients at specialist hospitals such as Royal Papworth and more generally for hospital patients. To date, 34 patients at Royal Papworth have contracted M abscessus from the hospital’s water . Cases continue to be reported , albeit at a declining rate;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Incomplete understanding of M abscessus entry into and colonisation of hospital water systems
Wider context from the report “2. There is an incomplete understanding of how M abscessus may enter and/or colonise a hospital water system ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on identification and control of M abscessus in hospital water systems
Wider context from the report “3. Health Technical Memorandum 04-01 Safe Water in Healthcare Premises was published by the Department of Health in 2016. It is concerned with the design, installation, commissioning and operation of hospital water systems. This guidance requires urgent review and amendment, whether by way of an Addendum or otherwise because:
a. It is a key document for hospital estate managers and Water Safety Groups;
b. It purports to provide comprehensive guidance on waterborne bacteria;
c. However, it provides no relevant guidance in relation to mycobacteria and none in relation to M abscessus . It provides no guidance on the identification and control of M abscessus . It does not require routine testing for mycobacteria, including M abscessus or provide guidance on acceptable levels (if any). Compliance with the guidance does not identify or guard against the risk from M abscessus ;
d. It provides no guidance on any additional measures that may be required in respect of “augmented care” patients, including those who are immunosuppressed;
e. It is not in any event consistent with British Standard BS 8580-2:2022 on Water Safety.
” 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 hospital water-safety guidance to align with British Standard BS 8580-2:2022
Wider context from the report “3. Health Technical Memorandum 04-01 Safe Water in Healthcare Premises was published by the Department of Health in 2016. It is concerned with the design, installation, commissioning and operation of hospital water systems. This guidance requires urgent review and amendment, whether by way of an Addendum or otherwise because:
a. It is a key document for hospital estate managers and Water Safety Groups;
b. It purports to provide comprehensive guidance on waterborne bacteria;
c. However, it provides no relevant guidance in relation to mycobacteria and none in relation to M abscessus. It provides no guidance on the identification and control of M abscessus. It does not require routine testing for mycobacteria, including M abscessus or provide guidance on acceptable levels (if any). Compliance with the guidance does not identify or guard against the risk from M abscessus;
d. It provides no guidance on any additional measures that may be required in respect of “augmented care” patients, including those who are immunosuppressed;
e. It is not in any event consistent with British Standard BS 8580-2:2022 on Water Safety .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England, as owner of the relevant guidance, is responsible for responding to the concerns about hospital water systems.
Verbatim wording from the response “Health Technical Memorandums are owned by NHS England (NHSE) and they are the correct organisation to respond to the concerns you raised in your report.” Source location Response from Department of Health and Social Care
Open published response
14 Nov 2022 Ghulam Mohammad · Prevention of Future Deaths report East London
View report summary
Concerns raised 5 Failure of investigation and inquest reporting to identify enoxaparin use and missing clinical justification View source Failure to prevent falls among high-risk hospital patients View source Inadequate recording of clinical factors supporting enoxaparin prescribing View source Failure to assess intracranial damage before prescribing and administering enoxaparin View source Delays in urgently requested CT head imaging View source See 2 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
Ghulam Mohammad · 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
Ghulam Mohammad, an 89-year-old man, was admitted to hospital after an unwitnessed fall and later sustained a head injury in a further hospital fall. His CT head was delayed for four days, and enoxaparin was prescribed and administered before the extent of any intracranial injury was known. The report also identifies inadequate record keeping and omissions in the initial investigation and consultant statement concerning the use of enoxaparin.
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 investigation and inquest reporting to identify enoxaparin use and missing clinical justification
Wider context from the report “5. Neither the Trust’s initial investigation nor the consultant statement to the inquest mentioned the use of enoxaparin or the lack of clinical records justifying its use .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent falls among high-risk hospital patients
Wider context from the report “1. A patient with a high risk of falls sustained a fatal injury in an avoidable fall in hospital .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording of clinical factors supporting enoxaparin prescribing
Wider context from the report “4. Inadequate record keeping meant that there was no contemporary account of the factors taken into consideration by the doctor or her supervising consultant in prescribing enoxaparin.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to assess intracranial damage before prescribing and administering enoxaparin
Wider context from the report “3. Before the requested CT head was undertaken, a doctor prescribed blood thinning medication – enoxaparin to Mr Mohammed. Enoxaparin can exacerbate an intra-cranial bleed. The medication was administered on 13 & 14th October 2021. Both the prescription and the administrations of enoxaparin were made without knowing the extent of any intra-cranial damage caused by the fall on 11/10/21.
” 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 urgently requested CT head imaging
Wider context from the report “2. Following that fall, an urgently requested CT head was delayed for four days .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Seek assurance from Trust leadership that patient-safety changes address fall prevention and staff training for prompt action after head injuries.
Verbatim wording from the response “I am writing to the Trust Chief Executive and the Chief Medical Officer seeking assurance that they do implement the changes to ensure patient safety is maintained both in preventing falls, but also ensuring staff have training to know when to act promptly should a head injury occur.” Source location Response from Department of Health and Social Care
Open published response
11 Nov 2022 Derek Shaw · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 2 Insufficient local NHS Trust capacity affecting ambulance attendance View source Delays in ambulance attendance 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
Derek Shaw · 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
Derek Shaw fell at home and became unwell the following morning, but an ambulance was delayed and he suffered a cardiac arrest before the crew arrived. The inquest heard that earlier ambulance attendance was likely to have meant he would not have died, and that ambulance availability was affected by a complex capacity problem involving local NHS trusts.
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 local NHS Trust capacity affecting ambulance attendance
Wider context from the report “(1) Evidence given at the inquest revealed that there was a delay in an ambulance attending to the deceased and that earlier arrival of an ambulance is likely to mean he would not have died when he did.
(2) The East of England Ambulance Service indicated that they did not consider that locally there were any further steps they could take and gave evidence this was a more complex problem involving local NHS Trusts and their capacity not just the ambulance service themselves .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance attendance
Wider context from the report “(1) Evidence given at the inquest revealed that there was a delay in an ambulance attending to the deceased and that earlier arrival of an ambulance is likely to mean he would not have died when he did .
(2) The East of England Ambulance Service indicated that they did not consider that locally there were any further steps they could take and gave evidence this was a more complex problem involving local NHS Trusts and their capacity not just the ambulance service themselves.
” 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 Deliver new ambulances and specialist mental health vehicles.
Verbatim wording from the response “Your report highlights that EEAST were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” Source location Response from Department of Health and Social Care
Open published response
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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 2024/25.
Verbatim wording from the response “Your report highlights that EEAST were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the delivery plan for recovering urgent and emergency care services.
Verbatim wording from the response “As the Minister responsible for urgent and emergency case services, I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times. 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 Provide additional funding to expand ambulance capacity and improve response times.
Verbatim wording from the response “Your report highlights that EEAST were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 3 Failure to ensure controlled and manageable discharge transfers between pressured care settings View source Inadequate staffing levels in residential homes receiving hospital patients View source Delays in availability of additional intermediate care bed capacity 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
David John Morganti and 3 others · 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
The report concerns several deaths involving delays in ambulance attendance and/or admission to Royal Cornwall Hospital, including deaths after falls, head injuries and a stroke. The principal concerns are the ongoing delays caused by ambulances being held at the hospital, limited intermediate and social care capacity, and the risk that unsafe or inadequately staffed discharge arrangements may worsen patients’ health and lead to readmission.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure controlled and manageable discharge transfers between pressured care settings
Wider context from the report “While there is an obvious need to discharge medically fit patients from Royal Cornwall Hospital, this has to be done in a controlled and manageable fashion . As set out above, GP representatives have drawn to my attention the extreme pressures primary care is currently under. Without more, it would seem to serve little purpose simply to transfer patients from one part of the system that is struggling to cope to a different part of the system that is equally challenged .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate staffing levels in residential homes receiving hospital patients
Wider context from the report “Similarly, it will not benefit patient health to discharge a patient from hospital to a residential home that does not have an appropriate level of staffing . All that will happen is that the patient will inevitably become de-conditioned, their illnesses will worsen and the result will be that they are likely to require re-admission.
” 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 availability of additional intermediate care bed capacity
Wider context from the report “While the successful completion of the ICB’s building project will go a long way to improving the capacity of intermediate care beds in the county, it is likely to be many months, if not years, before that additional capacity becomes available . My central concern is how the delays that are currently manifest can be mitigated in the intervening months, particularly given the likely increase in demand for ambulances/hospital admissions during the winter months.
” 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 Pilot new hospital discharge approaches through the Six National Discharge Frontunners.
Verbatim wording from the response “The Department is also working with NHSE on several important initiatives to embed best practice for discharging patients from hospitals. This includes the 100-day challenge, which is helping acute trusts improve patient flow based on using 10 best practice initiatives and the Six National Discharge Frontunners, which are piloting new approaches to discharge.” 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 funding available to support adult social care, hospital discharge and timely transfer into community care.
Verbatim wording from the response “We recognise that discharging people once they no longer need acute care improves their outcomes and reduces the risk of medical complications. To improve rates of safe hospital discharge and increase patient flow, the government is making available up to £2.8 billion this year and £4.7 billion in 2024-25 to support adult social care and discharge. This is alongside £700 million invested this winter, on top of £1.6 billion over the next two years, to support timely and safe discharge from hospital into the community.” 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 Fund community beds, discharge lounges and ambulance hubs to reduce hospital flow and ambulance handover delays.
Verbatim wording from the response “The NHS is also focussed on reducing the numbers of ambulance handover delays to hospitals. Alongside direct improvement support to the most challenged trusts, an additional £250 million was made available to enable the NHS to buy up beds in the community to safely discharge thousands of patients from hospital, and capital for discharge lounges and ambulance hubs. These measures have helped improve flow through hospitals and reduce ambulance handover delays. This is on top of the £500 million already invested last year.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with NHS England to embed hospital discharge best practice through the 100-day challenge.
Verbatim wording from the response “The Department is also working with NHSE on several important initiatives to embed best practice for discharging patients from hospitals. This includes the 100-day challenge, which is helping acute trusts improve patient flow based on using 10 best practice initiatives and the Six National Discharge Frontunners, which are piloting new approaches to discharge.” Source location Response from Department of Health and Social Care
Open published response
4 Nov 2022 Philip Geoffrey Day · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Failure to document, track and act on inter-clinician communications View source Lack of awareness of neutropenic sepsis guidance and red flags View source Insufficient emergency department capacity causing delays in triage, assessment and treatment View source Lack of a recognised information-sharing pathway between community clinicians and secondary care View source Failure of triage to prompt for neutropenic sepsis View source See 2 more concerns
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Philip Geoffrey Day · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Philip Geoffrey Day was treated with methotrexate for psoriatic arthritis and developed neutropenic sepsis after blood tests showed neutropenia and a raised CRP. He died in hospital on 15 April 2022 after developing ileitis and colitis, followed by cardiac arrest and multi-organ failure. Concerns included delays in triage, medical review and treatment; inadequate communication of information from community clinicians to hospital staff; and insufficient recognition of neutropenic sepsis risk factors and red flags.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to document, track and act on inter-clinician communications
Wider context from the report “2. In relation to Mr Day the inquest heard that the community OOH Doctor had correctly recognised the risk of neutropenic sepsis and had rung through to speak to a doctor at the hospital. At the inquest there was no documentation to assist in tracking that conversation or any evidence it had been recorded or acted on. It was clear from the evidence at the inquest that the sharing of information between community clinicians and secondary care was important and that there appears to be no recognised way for this to happened due to varied IT systems and no national recommendations for best practice in this scenario. As a consequence vital information is not available to ED teams.
” 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 awareness of neutropenic sepsis guidance and red flags
Wider context from the report “3. The Inquest heard that Mr Day’s first EWS score in ED was 2. He did not trigger on EWS for sepsis. However the blood tests in the community had shown a very low neutrophil level and a rising CRP. Had those factors been recognised along with his immunosuppression then he would have been treated under the neutropenic sepsis pathway earlier. The evidence suggested that there is a lack of awareness of the guidance and red flags for neutropenic sepsis which delays treatment . Greater awareness and triage questions that prompt for neutropenic sepsis would reduce the risk of neutropenic sepsis symptoms being missed at triage.
” 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 delays in triage, assessment and treatment
Wider context from the report “1. When Mr Day arrived in ED, it was struggling to cope with a large backlog . Waiting times on that night /morning were significant . Triage wait times were approximately 1 hour. The time to see a doctor rose through the night to 7 hours and 38 minutes by 6am. The inquest heard that this was due to sheer volumes and that this is a situation that still arises . The impact is a delay in patients being seen, assessed and treated promptly ;
” 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 recognised information-sharing pathway between community clinicians and secondary care
Wider context from the report “2. In relation to Mr Day the inquest heard that the community OOH Doctor had correctly recognised the risk of neutropenic sepsis and had rung through to speak to a doctor at the hospital. At the inquest there was no documentation to assist in tracking that conversation or any evidence it had been recorded or acted on. It was clear from the evidence at the inquest that the sharing of information between community clinicians and secondary care was important and that there appears to be no recognised way for this to happened due to varied IT systems and no national recommendations for best practice in this scenario . As a consequence vital information is not available to ED teams .
” 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 triage to prompt for neutropenic sepsis
Wider context from the report “3. The Inquest heard that Mr Day’s first EWS score in ED was 2. He did not trigger on EWS for sepsis. However the blood tests in the community had shown a very low neutrophil level and a rising CRP. Had those factors been recognised along with his immunosuppression then he would have been treated under the neutropenic sepsis pathway earlier. The evidence suggested that there is a lack of awareness of the guidance and red flags for neutropenic sepsis which delays treatment. Greater awareness and triage questions that prompt for neutropenic sepsis would reduce the risk of neutropenic sepsis symptoms being missed at triage .
” 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 Deliver 5,000 additional staffed, permanent hospital beds to improve patient flow and reduce emergency-department overcrowding.
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 have achieved the ambition of delivering 5,000 more staffed, permanent beds this year compared to 2022-23 plans - backed by £1 billion of dedicated funding. Further, we also achieved our target of scaling up virtual ward beds to over 10,000 in advance of winter.” Source location Response from Department of Health and Social Care
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise information-sharing processes between community out-of-hours services and emergency departments with NHS England.
Verbatim wording from the response “I have asked officials to further raise the processes for information sharing between community out-of-hours services and emergency departments, with NHS England” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make £1.6 billion available over two years to support timely hospital discharge and reduce admission waits from emergency departments.
Verbatim wording from the response “We recognise that a whole-system approach is needed to ensure people get the emergency care they need when they need it. This is why we 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.” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a two-year delivery plan to recover urgent and emergency care services.
Verbatim wording from the response “I recognise the pressures our A&E services are facing and the impact on waiting times for patients. That is why we published our 2-year Delivery plan for recovering urgent and emergency care services in January 2023, which aims to deliver sustained improvements in emergency waiting times. The ambition is to improve A&E wait times to 78% of patients being admitted, transferred, or discharged within four hours by March 2025.” Source location Response from Department of Health and Social Care
Open published response
4 Nov 2022 Ellen Lillian MacFarlane · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Unavailability of out-of-hours cardiac testing in District General Hospitals View source Delays in ambulance response caused by insufficient ambulance crews and vehicles View source Delays in deciding when to operate after further tests are pending over weekends 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
Ellen Lillian MacFarlane · 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
Ellen Lillian MacFarlane had an accidental fall at her care home and waited over five hours for an ambulance before being taken to hospital, where she was found to have a fractured neck of femur. She underwent surgery, subsequently deteriorated, and died at Tameside General Hospital. The concerns included delays in ambulance provision and difficulties obtaining cardiac tests at weekends, contributing to delays in deciding when to operate on fractured neck of femur patients.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of out-of-hours cardiac testing in District General Hospitals
Wider context from the report “2. Evidence before the inquest indicated that over a weekend Ellen MacFarlane required cardiac tests that could not be provided easily in a District General Hospital setting due to availability of services/staff at DGHs out of hours . As a consequence where an operation for a fractured neck of femur has been put on hold pending further tests there is an inbuilt additional delay over a weekend before a decision can be taken as to the optimum point at which to operate. This situation at DGHs appears to create a situation which is inconsistent with the drive to operate at the earliest possible point when a patient has been optimised to secure the best outcome as set out in the NICE 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 Delays in ambulance response caused by insufficient ambulance crews and vehicles
Wider context from the report “1. The inquest heard evidence that notwithstanding her age and frailty Ellen MacFarlane had to wait over 5 hours for an ambulance . This was due to the demands on the North West Ambulance Service on the day in question. The inquest heard that such delays were not unusual and were still occurring . The reason for the delay was a shortage of ambulance crews/vehicles due to a combination of high demand, staffing shortages and delays at ED ;
” 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 deciding when to operate after further tests are pending over weekends
Wider context from the report “2. Evidence before the inquest indicated that over a weekend Ellen MacFarlane required cardiac tests that could not be provided easily in a District General Hospital setting due to availability of services/staff at DGHs out of hours. As a consequence where an operation for a fractured neck of femur has been put on hold pending further tests there is an inbuilt additional delay over a weekend before a decision can be taken as to the optimum point at which to operate . This situation at DGHs appears to create a situation which is inconsistent with the drive to operate at the earliest possible point when a patient has been optimised to secure the best outcome as set out in the NICE Guidance.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish 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” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with NHS England to reduce ambulance waiting and response times.
Verbatim wording from the response “However, I recognise there is still more to do to reduce waiting/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
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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 “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
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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 ambulance workforce capacity through investment in NHS ambulance and support staff.
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 support future demand.” 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 to increase ambulance capacity.
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 additional funding to expand ambulance 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 £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
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing Trust governance addresses delays beyond 36 hours for fractured-hip surgery, including capacity reviews and root-cause analysis.
Verbatim wording from the response “My officials have consulted NHS England (NHSE) and the Care Quality Commission (CQC) regarding your concern over the availability of cardiac tests over the weekend. We are advised that, had there been an emergency need for scans outside of hours, that Ms MacFarlane would have been transferred to a tertiary centre. More broadly the Trust has governance in place to reduce delays outside the 36-hour timeframe to support compliance with NICE guidance for patients with a fractured neck of femur requiring surgery. This includes urgent review of theatre capacity by the divisional management team to schedule surgeries as soon as possible, and root cause analysis of misses to identify reasons for delays and opportunities for learning.” 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 Emergency cardiac scans outside normal hours are addressed by transferring patients to a tertiary centre.
Verbatim wording from the response “My officials have consulted NHS England (NHSE) and the Care Quality Commission (CQC) regarding your concern over the availability of cardiac tests over the weekend. We are advised that, had there been an emergency need for scans outside of hours, that Ms MacFarlane would have been transferred to a tertiary centre. More broadly the Trust has governance in place to reduce delays outside the 36-hour timeframe to support compliance with NICE guidance for patients with a fractured neck of femur requiring surgery. This includes urgent review of theatre capacity by the divisional management team to schedule surgeries as soon as possible, and root cause analysis of misses to identify reasons for delays and opportunities for learning.” 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 Ambulance performance is reviewed through the existing Strategic Partnership and Transformation Board.
Verbatim wording from the response “Your report raises concerns about ambulance response times by North West Ambulance Service NHS Trust (NWAS) and access to hospital services. In preparing this response, Departmental officials have made enquiries with NHS England. I have been reassured by NWAS that ambulance performance is reviewed regularly via the Strategic Partnership and Transformation Board, a joint committee between NWAS and the Integrated Care Boards in the region and I am pleased to note performance by NWAS has improved since this sad case.” Source location Response from Department of Health and Social Care
Open published response
4 Nov 2022 Peter Mantador Ross · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Poor maintenance of clinical records View source Failure to accurately report CT C-spine findings View source Failure to escalate identified CT Spine abnormalities to other clinicians View source Failure to record identified CT Spine abnormalities View source Repeated failures in communication between clinical teams and staff View source Failure to review CT C-spine images before burr-hole surgery View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Peter Mantador Ross · 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 Mantador Ross sustained a subdural haemorrhage and cervical spine fracture after falling down stairs at home on 8 July 2020. The spinal fracture was misinterpreted and remained undiagnosed; later failures to maintain immobilisation and delays in MRI contributed to cardiac arrest and severe neurological injury. He subsequently developed pneumonia following an aspiration episode, and the inquest found that neglect contributed to his death. Concerns also included failures to review and communicate CT findings and poor clinical record-keeping.
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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 Poor maintenance of clinical records
Wider context from the report “1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
4. Repeated failures in communication between; neurosurgical, emergency medicine, nursing staff, and physiotherapists led to serious harm to Mr Ross.
5. Clinical records were poorly maintained , exacerbating the lapses in communication between those treating Mr Ross.
” 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 accurately report CT C-spine findings
Wider context from the report “1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
4. Repeated failures in communication between; neurosurgical, emergency medicine, nursing staff, and physiotherapists led to serious harm to Mr Ross.
5. Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr Ross.
” 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 identified CT Spine abnormalities to other clinicians
Wider context from the report “1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
4. Repeated failures in communication between; neurosurgical, emergency medicine, nursing staff, and physiotherapists led to serious harm to Mr Ross.
5. Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr Ross.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to record identified CT Spine abnormalities
Wider context from the report “1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
4. Repeated failures in communication between; neurosurgical, emergency medicine, nursing staff, and physiotherapists led to serious harm to Mr Ross.
5. Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr Ross.
” 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 Repeated failures in communication between clinical teams and staff
Wider context from the report “1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
4. Repeated failures in communication between; neurosurgical, emergency medicine, nursing staff, and physiotherapists led to serious harm to Mr Ross.
5. Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr Ross.
” 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 review CT C-spine images before burr-hole surgery
Wider context from the report “1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
4. Repeated failures in communication between; neurosurgical, emergency medicine, nursing staff, and physiotherapists led to serious harm to Mr Ross.
5. Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr Ross.
” Open source report
4 Nov 2022 Lynn Moss · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to deliver urgent treatment where indicated in Emergency Departments View source Failure to provide timely and effective monitoring of patients’ conditions in Emergency Departments 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
Lynn Moss · 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
Mrs Moss was found seriously unwell on the floor at her home after apparently falling or collapsing and died the following day at Tameside General Hospital. At the hospital, she waited over five hours for a full medical assessment and around 19 hours for a bed, with missed opportunities to recognise deterioration. The principal concern was that sustained demand on Emergency Departments, linked to wider health and social care pressures, makes timely monitoring and urgent treatment increasingly difficult, creating an ongoing risk of future deaths.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to deliver urgent treatment where indicated in Emergency Departments
Wider context from the report “Notwithstanding such measures, it is a matter of residual concern that systemic problems within the health and social care sectors including difficulty in accessing primary care and delayed discharges combine to lead to persistently high levels of demand on hospital Emergency Departments. Such sustained demand makes timely and effective monitoring of a patient’s condition (and the delivery of urgent treatment where indicated ) increasingly difficult , thus creating an ongoing risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely and effective monitoring of patients’ conditions in Emergency Departments
Wider context from the report “Notwithstanding such measures, it is a matter of residual concern that systemic problems within the health and social care sectors including difficulty in accessing primary care and delayed discharges combine to lead to persistently high levels of demand on hospital Emergency Departments. Such sustained demand makes timely and effective monitoring of a patient’s condition (and the delivery of urgent treatment where indicated) increasingly difficult , thus creating an ongoing risk of future deaths.
” Open source report
21 Oct 2022 Daniel John O’Sullivan · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Delays in alerting police when psychiatric patients fail to return from leave View source Poor contemporaneous documentation of unescorted leave View source Failure of Serious Incident Investigations to investigate missing records and interview relevant witnesses View source Failure to formulate Care and Treatment plans identifying core treatment needs View source Failure to update suicide self-harm risk assessments View source Vulnerability of psychiatric patients on voluntary leave to self-harm and predation View source Failure of Serious Incident Investigations to investigate care and treatment plan deficiencies and make recommendations View source See 4 more concerns
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Daniel John O’Sullivan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel John O’Sullivan was found deceased on 27 March 2019 while a voluntary psychiatric patient at St Charles Hospital, after leaving the hospital unescorted and failing to return. The principal concerns were failures to update his self-harm risk assessment, formulate a care and treatment plan, document unescorted leave, and promptly notify police when he did not return. The report also raised concerns that the hospital’s serious incident investigation did not identify or investigate these issues adequately.
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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 Delays in alerting police when psychiatric patients fail to return from leave
Wider context from the report “2) My second concern is the poor contemporaneous documentation of the grant of unescorted leave from the hospital and the time taken to alert the police when Daniel failed to return on 26/3/19 by 21:00 pm. A ward nurse eventually contacted the police after midnight.
i) I am concerned that an earlier call to the police may have prevented the death, because Daniel was recorded on General Security Zone (GSZ) cameras at 22:21 leaving Vauxhall bridge, and returning, on foot at 23:48. An earlier call might have enabled police to intervene before he was able to commence the actions which ended his life.
ii) The ward manager claimed in evidence that he had instructed others to call the police when Daniel failed to return at 21:00. However, this was not documented anywhere in the medical records and a leave book with handwritten entries went missing after the death. The missing leave book was not investigated by the SII.
iii) A nurse who called the police, sometime before 00:30 according to the medical records, at 01:10 according to police records, was not interviewed by the SII.
I found these investigative deficits troubling because the learning of lessons in patient care depends, in part, on an early SII by the hospital concerned so that risks to patient safety can be identified to enable recommendations and improvements long before an inquest conclusion.
The delay in reporting the failure to return to the Ward was a factor that contributed to the dangerous situation already created by rescinding s.2.
I am nonetheless concerned that, in general, psychiatric patients being tested on voluntary leave are a vulnerable group and as such failures to return should be reported with expedition not only because they may be a danger to themselves, but also due to a risk of being preyed upon by others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor contemporaneous documentation of unescorted leave
Wider context from the report “2) My second concern is the poor contemporaneous documentation of the grant of unescorted leave from the hospital and the time taken to alert the police when Daniel failed to return on 26/3/19 by 21:00 pm. A ward nurse eventually contacted the police after midnight.
i) I am concerned that an earlier call to the police may have prevented the death, because Daniel was recorded on General Security Zone (GSZ) cameras at 22:21 leaving Vauxhall bridge, and returning, on foot at 23:48. An earlier call might have enabled police to intervene before he was able to commence the actions which ended his life.
ii) The ward manager claimed in evidence that he had instructed others to call the police when Daniel failed to return at 21:00. However, this was not documented anywhere in the medical records and a leave book with handwritten entries went missing after the death. The missing leave book was not investigated by the SII.
iii) A nurse who called the police, sometime before 00:30 according to the medical records, at 01:10 according to police records, was not interviewed by the SII.
I found these investigative deficits troubling because the learning of lessons in patient care depends, in part, on an early SII by the hospital concerned so that risks to patient safety can be identified to enable recommendations and improvements long before an inquest conclusion.
The delay in reporting the failure to return to the Ward was a factor that contributed to the dangerous situation already created by rescinding s.2.
I am nonetheless concerned that, in general, psychiatric patients being tested on voluntary leave are a vulnerable group and as such failures to return should be reported with expedition not only because they may be a danger to themselves, but also due to a risk of being preyed upon by others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of Serious Incident Investigations to investigate missing records and interview relevant witnesses
Wider context from the report “2) My second concern is the poor contemporaneous documentation of the grant of unescorted leave from the hospital and the time taken to alert the police when Daniel failed to return on 26/3/19 by 21:00 pm. A ward nurse eventually contacted the police after midnight.
i) I am concerned that an earlier call to the police may have prevented the death, because Daniel was recorded on General Security Zone (GSZ) cameras at 22:21 leaving Vauxhall bridge, and returning, on foot at 23:48. An earlier call might have enabled police to intervene before he was able to commence the actions which ended his life.
ii) The ward manager claimed in evidence that he had instructed others to call the police when Daniel failed to return at 21:00. However, this was not documented anywhere in the medical records and a leave book with handwritten entries went missing after the death. The missing leave book was not investigated by the SII.
iii) A nurse who called the police, sometime before 00:30 according to the medical records, at 01:10 according to police records, was not interviewed by the SII.
I found these investigative deficits troubling because the learning of lessons in patient care depends, in part, on an early SII by the hospital concerned so that risks to patient safety can be identified to enable recommendations and improvements long before an inquest conclusion.
The delay in reporting the failure to return to the Ward was a factor that contributed to the dangerous situation already created by rescinding s.2.
I am nonetheless concerned that, in general, psychiatric patients being tested on voluntary leave are a vulnerable group and as such failures to return should be reported with expedition not only because they may be a danger to themselves, but also due to a risk of being preyed upon by others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to formulate Care and Treatment plans identifying core treatment needs
Wider context from the report “1) On completion of the inquest, I found the decision to rescind detention under s.2 on 25/3/19 was undermined in two essential respects:
a) A failure to update a suicide self-harm risk assessment.
b) A failure to formulate a Care and Treatment plan identifying core treatment needs.
A Serious Incident Investigation (SII), commissioned by CNWL, completed on 9/9/2019, investigated the Risk Assessment and made recommendations which I heard from a CNWL witness had subsequently been implemented and I am satisfied that his risk to life has been satisfactorily reduced.
However, I remain concerned that the Care and Treatment plan aspect was not identified by the SII and as such no recommendations were identified and followed up.
The psychiatrist who rescinded s.2, on 25/3/2019, was unable to participate in the inquest through illness.
As a result, I instructed an independent expert psychiatrist who gave evidence that there had been no treatment plan addressing Daniel’s core treatment needs.
The core treatment needs were that Daniel required antipsychotic medication to control his delusional beliefs and psychological intervention to address his substance misuse which exacerbated his delusional beliefs.
The expert also identified from statements and medical records that Daniel lacked insight into his mental health conditions and thereby lacked capacity. The treatment Daniel required was twofold. Assertive treatment of the delusional disorder with antipsychotics, whilst detained under s.2, to achieve stability, coupled with psychological therapy to address the illicit drug use.
I heard evidence that antipsychotics could not commence until the results of liver function tests were available, but this did not persuade the expert, that recession of s.2 was correct.
The psychiatrist who rescinded s.2 on 25/3/19 was interviewed by the SII but the care and treatment plan aspect was not explored by that investigation.
My concern is that failures in the formulation of a Care and Treatment Plan made a significant contribution to the death and this failing was not exposed until the inquest when it could have been identified much earlier by the SII in September 2019.
The fact that a Care and Treatment plan was not formulated gives me concern that the mistake could be repeated in future and my concern is compounded by the SII failing to investigate and make recommendations arising from this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to update suicide self-harm risk assessments
Wider context from the report “1) On completion of the inquest, I found the decision to rescind detention under s.2 on 25/3/19 was undermined in two essential respects:
a) A failure to update a suicide self-harm risk assessment.
b) A failure to formulate a Care and Treatment plan identifying core treatment needs.
A Serious Incident Investigation (SII), commissioned by CNWL, completed on 9/9/2019, investigated the Risk Assessment and made recommendations which I heard from a CNWL witness had subsequently been implemented and I am satisfied that his risk to life has been satisfactorily reduced.
However, I remain concerned that the Care and Treatment plan aspect was not identified by the SII and as such no recommendations were identified and followed up.
The psychiatrist who rescinded s.2, on 25/3/2019, was unable to participate in the inquest through illness.
As a result, I instructed an independent expert psychiatrist who gave evidence that there had been no treatment plan addressing Daniel’s core treatment needs.
The core treatment needs were that Daniel required antipsychotic medication to control his delusional beliefs and psychological intervention to address his substance misuse which exacerbated his delusional beliefs.
The expert also identified from statements and medical records that Daniel lacked insight into his mental health conditions and thereby lacked capacity. The treatment Daniel required was twofold. Assertive treatment of the delusional disorder with antipsychotics, whilst detained under s.2, to achieve stability, coupled with psychological therapy to address the illicit drug use.
I heard evidence that antipsychotics could not commence until the results of liver function tests were available, but this did not persuade the expert, that recession of s.2 was correct.
The psychiatrist who rescinded s.2 on 25/3/19 was interviewed by the SII but the care and treatment plan aspect was not explored by that investigation.
My concern is that failures in the formulation of a Care and Treatment Plan made a significant contribution to the death and this failing was not exposed until the inquest when it could have been identified much earlier by the SII in September 2019.
The fact that a Care and Treatment plan was not formulated gives me concern that the mistake could be repeated in future and my concern is compounded by the SII failing to investigate and make recommendations arising from this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Vulnerability of psychiatric patients on voluntary leave to self-harm and predation
Wider context from the report “2) My second concern is the poor contemporaneous documentation of the grant of unescorted leave from the hospital and the time taken to alert the police when Daniel failed to return on 26/3/19 by 21:00 pm. A ward nurse eventually contacted the police after midnight.
i) I am concerned that an earlier call to the police may have prevented the death, because Daniel was recorded on General Security Zone (GSZ) cameras at 22:21 leaving Vauxhall bridge, and returning, on foot at 23:48. An earlier call might have enabled police to intervene before he was able to commence the actions which ended his life.
ii) The ward manager claimed in evidence that he had instructed others to call the police when Daniel failed to return at 21:00. However, this was not documented anywhere in the medical records and a leave book with handwritten entries went missing after the death. The missing leave book was not investigated by the SII.
iii) A nurse who called the police, sometime before 00:30 according to the medical records, at 01:10 according to police records, was not interviewed by the SII.
I found these investigative deficits troubling because the learning of lessons in patient care depends, in part, on an early SII by the hospital concerned so that risks to patient safety can be identified to enable recommendations and improvements long before an inquest conclusion.
The delay in reporting the failure to return to the Ward was a factor that contributed to the dangerous situation already created by rescinding s.2.
I am nonetheless concerned that, in general, psychiatric patients being tested on voluntary leave are a vulnerable group and as such failures to return should be reported with expedition not only because they may be a danger to themselves, but also due to a risk of being preyed upon by others .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of Serious Incident Investigations to investigate care and treatment plan deficiencies and make recommendations
Wider context from the report “1) On completion of the inquest, I found the decision to rescind detention under s.2 on 25/3/19 was undermined in two essential respects:
a) A failure to update a suicide self-harm risk assessment.
b) A failure to formulate a Care and Treatment plan identifying core treatment needs.
A Serious Incident Investigation (SII), commissioned by CNWL, completed on 9/9/2019, investigated the Risk Assessment and made recommendations which I heard from a CNWL witness had subsequently been implemented and I am satisfied that his risk to life has been satisfactorily reduced.
However, I remain concerned that the Care and Treatment plan aspect was not identified by the SII and as such no recommendations were identified and followed up.
The psychiatrist who rescinded s.2, on 25/3/2019, was unable to participate in the inquest through illness.
As a result, I instructed an independent expert psychiatrist who gave evidence that there had been no treatment plan addressing Daniel’s core treatment needs.
The core treatment needs were that Daniel required antipsychotic medication to control his delusional beliefs and psychological intervention to address his substance misuse which exacerbated his delusional beliefs.
The expert also identified from statements and medical records that Daniel lacked insight into his mental health conditions and thereby lacked capacity. The treatment Daniel required was twofold. Assertive treatment of the delusional disorder with antipsychotics, whilst detained under s.2, to achieve stability, coupled with psychological therapy to address the illicit drug use.
I heard evidence that antipsychotics could not commence until the results of liver function tests were available, but this did not persuade the expert, that recession of s.2 was correct.
The psychiatrist who rescinded s.2 on 25/3/19 was interviewed by the SII but the care and treatment plan aspect was not explored by that investigation.
My concern is that failures in the formulation of a Care and Treatment Plan made a significant contribution to the death and this failing was not exposed until the inquest when it could have been identified much earlier by the SII in September 2019.
The fact that a Care and Treatment plan was not formulated gives me concern that the mistake could be repeated in future and my concern is compounded by the SII failing to investigate and make recommendations arising from this issue .
” 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 Establish a statutory duty for clinicians to create care and treatment plans for patients detained under the Mental Health Act.
Verbatim wording from the response “We are aware through the independent review of the Mental Health Act and subsequent White Paper consultation, and according to the Care Quality Commission, that care planning is sometimes not to the high standards required by the Code of Practice. This is why the draft Mental Health Bill, which was published on 27 June 2022, proposes a statutory duty on clinicians to create a care and treatment plan for all relevant patients detained under the Mental Health Act (including, but not limited to, section 2 and section 3 patients), to help ensure that greater respect and attention is given to care and treatment planning.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 1 Delays in children and young people's access to mental health treatment and support 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
Charley Ann Patterson · 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
Charley Ann Patterson had experienced low mood, anxiety, bullying and previous self-harm. She attended hospital for support in May 2020, but the planned referral to the Northumberland (Early Help) Hub was not made and there was an absence of communication with other services and professionals. She later died by suicide on 1 October 2020. The concerns included increased demand for children’s mental health support following the Coronavirus pandemic and delays in receiving treatment and early 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 Delays in children and young people's access to mental health treatment and support
Wider context from the report “(1) During the course of the inquest, it was a concern to me the increase in the number of children and young people who are now being seen with regard to their emotional well-being, psychological distress and mental health difficulties which have impacted on them requiring support and assessment since the Coronavirus pandemic and the delays that now exist before they receive treatment and support .
(2) I heard that in 2020 if the criteria for referral had been met for referral to Children's Adolescent Mental Health Services there would have been a triage of the child or young person within 8 weeks, treatment within up to 19 weeks with the number of referrals at that time being 1,595. In 2022, subject to meeting the criteria for referral, there would be a triage of the child or young person within 3 weeks but that waiting time for treatment has increased from up to 19 weeks up to 63 weeks with the number of referrals being 2,275.
” Open source report
14 Oct 2022 Neha Susan RAJU · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Lack of protection for vulnerable people before purchases View source Availability of lethal quantities for internet purchase and UK delivery View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Neha Susan RAJU · 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
Neha Susan Raju was found deceased by emergency services in her bedroom in Guildford, Surrey, on 10 April 2022 after her family raised concerns that she was not responding to calls or messages. The report identified concerns that a substance was freely available to purchase online in lethal quantities for delivery within the UK, with no protection for vulnerable people before such purchases were made.
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 protection for vulnerable people before purchases
Wider context from the report “- No protection is afforded to vulnerable people prior to them making such purchases
” 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 Availability of lethal quantities for internet purchase and UK delivery
Wider context from the report “- ████████ is freely available to be purchased from the internet in lethal quantities for delivery within the UK
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work closely with the Home Office on safeguards concerning public access to the chemical and sellers’ suspicious-transaction reporting obligations.
Verbatim wording from the response “With regard to the sale of the chemical used in this case, Department officials work closely with the Home Office on this matter, and I understand from them that this chemical is available to the public for legitimate uses. It is, however, included in The Poisons Act 1972 as a reportable substance, meaning that while it is generally available without the need for a licence, sellers (including online sellers) are obligated to make suspicious transaction reports, whether they process the transaction or not, where they have grounds to believe that the sale is for an illicit use.” 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 Regulation of the substance purchased online as a non-licensed or counterfeit medicine falls outside the MHRA’s remit.
Verbatim wording from the response “In preparing this response, Departmental officials have made enquiries with the Medicines and Healthcare products Regulatory Agency (MHRA). The MHRA have advised that they are responsible for regulating the substance used in this case, when it is used as a licensed medicine, in the form of a solution for injection. It is a prescription only medicine and has an indication for cyanide poisoning. This substance in other forms is used in other sectors, such as food manufacturing. However, when the purchase of this substance over the internet is not a licensed medicine, or counterfeit medicine, it is not within the remit of the MHRA.” Source location Response from Department of Health and Social Care
Open published response
13 Oct 2022 Oli Akram Hoque · Prevention of Future Deaths report East London
View report summary
Concerns raised 1 Inability to compel timely production of relevant clinical data for safety investigations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Oli Akram Hoque · 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
Oli Akram Hoque developed worsening headaches after receiving his first AstraZeneca COVID-19 vaccination and later suffered seizures; investigations revealed cerebral venous sinus thrombosis, and he died in hospital on 15 April 2021. The principal concern was that the MHRA could not compel the timely production of relevant clinical data needed for robust vaccine safety investigations.
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 Inability to compel timely production of relevant clinical data for safety investigations
Wider context from the report “The Inquest heard evidence from a senior medical assessor from the Medicines and Healthcare Regulatory Agency (MHRA). The Inquest heard that from the 25th February 2021 the MHRA investigated the potential signal of immune thrombocytopenia. This identified three cases of cerebral venous sinus thrombosis which could possibly be associated with the Astra Zeneca COVID 19 vaccine. The MHRA could not fully consider these cases as they did not receive all of the necessary clinical information. The Inquest heard that the MHRA do not have the power to compel relevant clinical information, to assist them with safety investigations .
In light of the clear public interest in ensuring that the MHRA are able to carry out robust safety investigations, it is a matter of concern that the MHRA are unable to compel the timely production of relevant clinical data .
” 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 Establish relevant data flows before vaccination commenced to support proactive pharmacovigilance surveillance.
Verbatim wording from the response “MHRA recognises the importance of access to relevant clinical information for pharmacovigilance and ensured that relevant data flows were in place prior to commencement of vaccinations in December 2020 to support its four-stranded proactive vigilance strategy - 1) Enhanced passive surveillance – ‘observed vs expected’ analysis; 2) Rapid Cycle Analysis and Ecological analysis (analysing anonymised healthcare for pre-defined events as well as monitoring trends); 3) Targeted active monitoring; and 4) Formal epidemiological studies. It is the view of the MHRA that focus should be placed on encouraging reporting and working across the health family to streamline processes and reduce barriers to reporting.” 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 Conduct proactive follow-up and use data-sharing arrangements to obtain additional pharmacovigilance case details.
Verbatim wording from the response “MHRA conducted daily, proactive follow up and utilised a Data Sharing Agreement (DSA) with Public Health England (now UK Health Security Agency, UKHSA) for additional case details where needed. MHRA sought the advice of its COVID-19 Expert Working Group and the Commission on Human Medicines on emerging advice of timeframe for thrombosis with thrombocytopenia and issued regular press releases as evidence continued to amass.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the NHS to improve reporting-system interoperability and connectivity, including automatic electronic transfer from LPSE to MHRA databases.
Verbatim wording from the response “Steps taken to enable this include working with the NHS to enable interoperability and connectivity of reporting system such as the new Learning from Patient Safety Events System (LPSE) to allow automatic electronic upload into MHRA databases in a timely manner. The NHS Digital Clinical Safety Strategy¹ covers integration of LPSE with the Yellow Card system; improvement of adverse events and incident reporting is a commitment made by NHS and MHRA with a clear strategy and shared responsibilities. A recently published NHS standard contract (NHS England “2023/24 NHS Standard Contract) has a focus on interoperability which will help achieve those aims.²” 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 MHRA lacks jurisdiction over healthcare professionals and therefore cannot comment on legislative powers to access NHS case notes.
Verbatim wording from the response “MHRA do not have jurisdiction over healthcare professionals, and therefore did not comment on your consideration of whether issuance of this Regulation 28 report regarding legislative powers to access NHS case notes would assist the MHRA. There are professional guidelines in place for healthcare professionals to report safety issues, however, the Department is not aware of any jurisdiction globally that compels relevant clinical follow up information.” Source location Response from Department of Health and Social Care
Open published response
5 Oct 2022 Charles Stephen Rothwell · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 3 Lack of resources across primary, secondary and social care View source Delays in handing over ambulance patients at A&E departments View source Failure to match ambulance response capacity to demand 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
Charles Stephen Rothwell · 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
Charles Stephen Rothwell was diagnosed with a chest infection on 5 January 2022, deteriorated the following day, and died after repeated 999 calls and a delayed ambulance response. The principal concern was that emergency ambulance demand continued to outstrip available capacity, creating a risk of future deaths, with wider pressures across primary, secondary and social care contributing to delays.
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 resources across primary, secondary and social care
Wider context from the report “1) NWAS have developed a new triage system and have adopted NHS Pathways, which means that the initial call would now be triaged as Category 1 or 2. However, the problem of demand outstripping supply remains, such that if the same 999 call were made today the outcome would be the same.
2) NWAS continues to experience “exceptionally high demand” with the effect that “the demand completely outstrips the capability [they] have got.”
3) By way of example, I was told that yesterday afternoon Category 2 responses (which should attract attendance within 18 minutes) were sitting at an average of 75 minutes, Category 3 responses (which should attract attendance within 120 minutes) were sitting at an average of 10.5h and category 4 responses (which should prompt a further telephone assessment within 90 – 180 minutes) were sitting at an average of 11.5h.
4) With the approach of winter NWAS are also beginning to see an even greater increase in demand on top of the existing demand.
5) The problem is not due to a shortage of NWAS ambulances or staff but instead is the result of a wider issue linked to the lack of resources in primary, secondary and social care . This results in demand for ambulances outstripping supply and a backlog of ambulances waiting to handover patients at A&E departments because of a shortage of A&E beds, which in turn is because of shortages in social care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in handing over ambulance patients at A&E departments
Wider context from the report “1) NWAS have developed a new triage system and have adopted NHS Pathways, which means that the initial call would now be triaged as Category 1 or 2. However, the problem of demand outstripping supply remains, such that if the same 999 call were made today the outcome would be the same.
2) NWAS continues to experience “exceptionally high demand” with the effect that “the demand completely outstrips the capability [they] have got.”
3) By way of example, I was told that yesterday afternoon Category 2 responses (which should attract attendance within 18 minutes) were sitting at an average of 75 minutes, Category 3 responses (which should attract attendance within 120 minutes) were sitting at an average of 10.5h and category 4 responses (which should prompt a further telephone assessment within 90 – 180 minutes) were sitting at an average of 11.5h.
4) With the approach of winter NWAS are also beginning to see an even greater increase in demand on top of the existing demand.
5) The problem is not due to a shortage of NWAS ambulances or staff but instead is the result of a wider issue linked to the lack of resources in primary, secondary and social care. This results in demand for ambulances outstripping supply and a backlog of ambulances waiting to handover patients at A&E departments because of a shortage of A&E beds , which in turn is because of shortages in social care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to match ambulance response capacity to demand
Wider context from the report “1) NWAS have developed a new triage system and have adopted NHS Pathways, which means that the initial call would now be triaged as Category 1 or 2. However, the problem of demand outstripping supply remains , such that if the same 999 call were made today the outcome would be the same.
2) NWAS continues to experience “exceptionally high demand” with the effect that “the demand completely outstrips the capability [they] have got .”
3) By way of example, I was told that yesterday afternoon Category 2 responses (which should attract attendance within 18 minutes) were sitting at an average of 75 minutes , Category 3 responses (which should attract attendance within 120 minutes) were sitting at an average of 10.5h and category 4 responses (which should prompt a further telephone assessment within 90 – 180 minutes) were sitting at an average of 11.5h .
4) With the approach of winter NWAS are also beginning to see an even greater increase in demand on top of the existing demand.
5) The problem is not due to a shortage of NWAS ambulances or staff but instead is the result of a wider issue linked to the lack of resources in primary, secondary and social care. This results in demand for ambulances outstripping supply and a backlog of ambulances waiting to handover patients at A&E departments because of a shortage of A&E beds, which in turn is because of shortages in social care.
” Open source report
4 Oct 2022 Reginald Cauthery · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Failure to review telecare services in light of increased fire risk and deteriorating mobility View source Failure to answer telecare fire calls as a priority View source Dependence on other people recognising smoke alarms and calling the Fire Brigade for urgent fire assistance View source Smoke alarms not connected to telecare systems View source Delays in calling 999 while seeking confirmation of smoke alarm activation 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
Reginald Cauthery · 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
Reginald Cauthery was a frail man with limited mobility who lived alone and died in hospital after sustaining extensive burns in a smouldering fire at his flat. The report raised concerns that his telecare service was not reviewed despite his increased fire risk and deteriorating mobility, and that his smoke alarms were not connected to the telecare system, delaying contact with the Fire Brigade.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to review telecare services in light of increased fire risk and deteriorating mobility
Wider context from the report “(1) There was no review of the telecare service provided to Mr Cauthery despite the agencies working with him being aware of his increased fire risk and deteriorating mobility .
” 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 answer telecare fire calls as a priority
Wider context from the report “(3) If Mr Cauthery’s smoke alarm had been connected to his telecare system, the call would have been answered as a priority . In addition, the call handler would not have spent several minutes seeking confirmation that the smoke alarm was going off before making a 999 call.
” 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 Dependence on other people recognising smoke alarms and calling the Fire Brigade for urgent fire assistance
Wider context from the report “(2) The ability of frail and vulnerable people to get urgent help in a fire situation will often depend upon other people recognising that a smoke alarm has triggered and calling the Fire Brigade . This raises particular problems if the person lives alone and their smoke alarm is not connected to their telecare system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Smoke alarms not connected to telecare systems
Wider context from the report “(2) The ability of frail and vulnerable people to get urgent help in a fire situation will often depend upon other people recognising that a smoke alarm has triggered and calling the Fire Brigade. This raises particular problems if the person lives alone and their smoke alarm is not connected to their telecare system .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in calling 999 while seeking confirmation of smoke alarm activation
Wider context from the report “(3) If Mr Cauthery’s smoke alarm had been connected to his telecare system, the call would have been answered as a priority. In addition, the call handler would not have spent several minutes seeking confirmation that the smoke alarm was going off before making a 999 call .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the “What Good Looks Like” framework, including guidance for local authorities on considering technology-enabled care and linked preventative devices.
Verbatim wording from the response “This Department published the “What Good Looks Like” framework for adult social care on 16 May. It is available on GOV.UK. The framework has been developed as part of Department of Health and Social Care and NHS England guidance to support health and care organisations with digitisation. The What Good Looks Like framework aims to bring together the needs of local authorities and care providers into one coherent guidance document that helps them to understand what they need to do to work well digitally.” 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 Issue an updated Adult Social Care Digital Skills Framework supporting workforce training and regular review of technology use in care plans.
Verbatim wording from the response “Also issued on 16 May by this Department was an updated Adult Social Care Digital Skills Framework to help support the development of digital skills across the adult social care workforce. It can be used by social care employers to help with planning staff training, or by individuals for their personal development. This updated framework will support social care workers to understand the importance of, and develop the skills to regularly review, how technology is used to support care within people’s care plans. Further information can be found at www.digitalsocialcare.co.uk/digital-skills-and-training/digital-skills-framework.” 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 Local authorities commissioning telecare services determine contract requirements, including device maintenance and reviewing device use.
Verbatim wording from the response “Telecare services are provided by local authorities, housing associations, the third sector and by commercial organisations. Not all local authorities provide or commission telecare services, but telecare is an intervention linked to the Care Act of 2014 and that Act’s responsibilities of preventing, reducing, or delaying the development of care and support needs or in meeting individual eligible needs for care and support. Where local authorities are commissioning telecare services, they will agree their own contracts in doing so, including how telecare devices should be maintained and their use reviewed.” Source location Response from Department of Health and Social Care
Open published response
30 Sep 2022 Shahan Abu Aman · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to verify the most recent clinical observations and PEWS score before discharge View source Failure of nursing and paediatric medical staff to communicate factors affecting patients and plans to resolve them before discharge View source Pressurised Paediatric Emergency Department environment caused by high patient numbers and severe symptom acuity View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Shahan Abu Aman · 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
Shahan Abu Aman, a three-year-old boy, attended hospital on 7 December 2021 with vomiting and diarrhoea and was discharged after assessment, observation and a fluid challenge. He was found unresponsive the following morning and died in hospital; the report identified miscommunication between nursing and medical staff, failure to confirm the most recent observations and PEWS score before discharge, and a pressurised emergency department environment as concerns.
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 verify the most recent clinical observations and PEWS score before discharge
Wider context from the report “2. The doctor who authorised discharge did not satisfy himself of the most recent set of clinical observations and associated Paediatric Early Warning Sign (PEWS) score prior to 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 Failure of nursing and paediatric medical staff to communicate factors affecting patients and plans to resolve them before discharge
Wider context from the report “1. A series of miscommunications between; nursing staff, junior and consultant paediatric medical staff resulted in concerns regarding Aman not being properly considered prior to discharge. Staff relied on assumptions that others understood the factors affecting Aman and had a plan to resolve them, this was not the case. Had effective communication occurred it was unlikely that Aman would have been discharged.
” 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 Pressurised Paediatric Emergency Department environment caused by high patient numbers and severe symptom acuity
Wider context from the report “3. The Paediatric Emergency Department was particularly busy that evening, with a combination of high patient numbers and severe acuity of symptoms . The accounts provided by Trust witnesses was that this resulted in a pressurised environment and that this was a situation that occurred with an increasing level of frequency over the last two years .
” 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 Expand and promote NHS111 online to improve access to appropriate care.
Verbatim wording from the response “The plan will also grow the NHS111 clinical workforce, make urgent mental health support universally available in 111 services, and expand and promote NHS111 online to ensure patients can access the right care first time, and only visit A&E when necessary.” 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 Expand and integrate health and care services outside hospital, including urgent community response, frailty and falls services nationwide.
Verbatim wording from the response “We are expanding and better joining up health and care outside hospital helping to reduce admissions to A&E, including scaling urgent community response, frailty and falls services across the whole country.” 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 Add 3,000 virtual ward beds, increasing the total to over 10,000 by autumn.
Verbatim wording from the response “We will also make greater use of ‘virtual wards’, with an extra 3,000 virtual ward beds to provide over 10,000 in total by this autumn, allowing patients to be safely monitored and supported towards recovery from the comfort of their own home. Longer term, we will build capacity to allow staff to care for up to 50,000 patients a month this way.” 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 Introduce new approaches to step-down care to reduce delayed hospital discharge.
Verbatim wording from the response “We are also investing £1.6 billion over the next 2 years to reduce the numbers of beds occupied by patients ready to be discharged. This includes establishing ‘Care transfer hubs’ in every hospital ahead of next winter, alongside new approaches to step-down care.” 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 beds and 800 new ambulances to increase urgent and emergency care capacity.
Verbatim wording from the response “To increase capacity and reduce waits, the plan will deliver 5,000 more staffed, permanent beds this year compared to 2022/23 plans, alongside 800 new ambulances including speciality mental health vehicles. This is backed by £1 billion of dedicated funding.” 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 Establish Same Day Emergency Care services across every hospital with a major emergency department.
Verbatim wording from the response “Same Day Emergency Care services will also be in place across every hospital with a major emergency department, helping avoid unnecessary overnight stays in hospital.” 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 urgent mental health support universally available through NHS111 services.
Verbatim wording from the response “The plan will also grow the NHS111 clinical workforce, make urgent mental health support universally available in 111 services, and expand and promote NHS111 online to ensure patients can access the right care first time, and only visit A&E when necessary.” 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 Build longer-term virtual ward capacity to support care for up to 50,000 patients monthly.
Verbatim wording from the response “We will also make greater use of ‘virtual wards’, with an extra 3,000 virtual ward beds to provide over 10,000 in total by this autumn, allowing patients to be safely monitored and supported towards recovery from the comfort of their own home. Longer term, we will build capacity to allow staff to care for up to 50,000 patients a month this way.” 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 Establish Care Transfer Hubs in every hospital ahead of the following winter.
Verbatim wording from the response “We are also investing £1.6 billion over the next 2 years to reduce the numbers of beds occupied by patients ready to be discharged. This includes establishing ‘Care transfer hubs’ in every hospital ahead of next winter, alongside new approaches to step-down care.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £1.6 billion over two years to reduce the number of beds occupied by patients ready for discharge.
Verbatim wording from the response “We are also investing £1.6 billion over the next 2 years to reduce the numbers of beds occupied by patients ready to be discharged. This includes establishing ‘Care transfer hubs’ in every hospital ahead of next winter, alongside new approaches to step-down care.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Grow the NHS111 clinical workforce.
Verbatim wording from the response “The plan will also grow the NHS111 clinical workforce, make urgent mental health support universally available in 111 services, and expand and promote NHS111 online to ensure patients can access the right care first time, and only visit A&E when necessary.” Source location Response from Department of Health and Social Care
Open published response
29 Sep 2022 Charlotte Emma Warkcup · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 3 Insufficient recruitment and retention of midwives for continuity of care View source Insufficient detection of babies who are small for gestational age View source Safety hazard of standalone midwife-led birthing centres without immediate onsite access to a hospital maternity unit View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Charlotte Emma Warkcup · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Charlotte Emma Warkcup died at Sunderland Royal Hospital on 23 December 2021, two days after she was born. The report described concerns about delayed recognition of the severity of her condition, delays transferring her mother to hospital, and delayed access to the delivery suite. It also identified concerns about the safety of standalone midwife-led birthing centres, midwife recruitment and retention, and detection of babies who are small for gestational age.
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 recruitment and retention of midwives for continuity of care
Wider context from the report “2. The recruitment and retention of midwives to ensure continuity of care
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient detection of babies who are small for gestational age
Wider context from the report “3. The improved detection of babies who are of small gestational age
” 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 Safety hazard of standalone midwife-led birthing centres without immediate onsite access to a hospital maternity unit
Wider context from the report “1. Whether standalone midwife led birthing centres are a safe environment for delivery as opposed to those with immediate onsite access to a maternity unit within a hospital
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide non-repayable annual training grants and additional financial support for eligible students and recruitment-shortage specialisms.
Verbatim wording from the response “And as part of the biggest nursing, midwifery and Allied Health Professional recruitment drive in decades, since September 2020, the Government has made available:” 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 Implement the NHS People Plan’s staff-retention measures, including wellbeing guardians, healthier working environments, flexible working and psychological support.
Verbatim wording from the response “To improve working conditions to deter people from leaving the profession, the NHS People Plan has been developed to focus on improving the retention of NHS staff by prioritising staff health and wellbeing. This includes a wellbeing guardian role, a focus on healthy working environments, and empowering line managers to hold meaningful conversations with staff to discuss their wellbeing, and a comprehensive emotional and psychological health and wellbeing support package.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and apply the Saving Babies’ Lives Care Bundle guidance to support safer maternity care and reduce stillbirths.
Verbatim wording from the response “The Government’s Maternity Safety Ambition is to halve the 2010 rates of stillbirths, neonatal and maternal deaths and brain injuries in babies occurring during or soon after birth by 2025. The ambition also includes reducing the rate of pre-term births from 8% to 6% by 2025.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and publish version 3 of the Saving Babies’ Lives Care Bundle with more nuanced risk assessment and clearer practical guidance.
Verbatim wording from the response “The Saving Babies’ Lives Care Bundle (SBLCB) is a set of guidance that was developed to support progress of the stillbirth element of the ambition, and brings together four key elements of care based on best available evidence and practice in order to help reduce stillbirth rates. This supports commissioners, providers and professionals in making care safer for women and babies. The elements of care brought together by the SBLCB include: Risk assessment and surveillance for fetal growth restriction; Raising awareness of reduced fetal movement; and Effective fetal monitoring during labour.” 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 Invest £165 million to grow and support the maternity workforce and improve neonatal care.
Verbatim wording from the response “The Department recognises that professional staff is the NHS’s most valuable asset, and the importance of ensuring that maternity units have the appropriate number and mix of staff to deliver high quality care for all women.” 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 Expand midwifery training places by 3,650 over four years.
Verbatim wording from the response “The Government has also committed to expanding midwifery training places by 3,650 over a four-year period with an increase of 650 in September 2019 and 1,000 in each of the subsequent years.” 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 Evidence indicates freestanding midwifery units are safe for low-risk births, with no significant adverse outcome difference from obstetric units.
Verbatim wording from the response “The study found that for 'low risk' women, the incidence of adverse perinatal outcomes was low (4.3 events per 1000 births). For planned births in freestanding midwifery units and alongside midwifery there were no significant differences in adverse perinatal outcomes compared with planned birth in an obstetric unit. Women who planned birth in a midwifery unit (AMU or FMU) had significantly fewer interventions, including substantially fewer intrapartum caesarean sections, and more 'normal births' than women who planned birth in an obstetric unit.” Source location Response from Department of Health and Social Care
Open published response
15 Sep 2022 Harper DENTON · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 4 Lack of an offender register or equivalent protection for children from people convicted of cruelty against a child View source Failure to require Health Visitors to conduct full safeguarding assessments of fathers’ or co-parents’ potential risks to children View source Failure to adopt MOSOVO guidance for managing sexual and violent offenders, particularly PDPs View source Lack of proactive police information sharing to protect children from people convicted of violence or cruelty against a child 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
Harper DENTON · 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
Harper DENTON, aged one month, was unlawfully killed by her father, who had previously been convicted of violent offences against a two-year-old child. The inquest found that failures by state agencies to manage the continuing risk he posed contributed to her death. Concerns included police information-sharing and risk-management practices, the absence of an offender register for people convicted of cruelty offences against children, and the non-mandatory nature of full safeguarding assessments by health visitors.
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 an offender register or equivalent protection for children from people convicted of cruelty against a child
Wider context from the report “3. There is nothing today, such as form of Offender Register, to protect children from an individual who has already been convicted of a cruelty offence against a child and served their sentence.
” 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 require Health Visitors to conduct full safeguarding assessments of fathers’ or co-parents’ potential risks to children
Wider context from the report “4.The need for a Health Visitor to carry out a full safeguarding assessment of a father’s/co-parent's potential risks to a child is currently only ‘best practice’ and not mandatory .
” 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 MOSOVO guidance for managing sexual and violent offenders, particularly PDPs
Wider context from the report “1.The MPS does not appear to have adopted ACPO Guidance on Protecting the Public: Managing Sexual Offenders and Violent Offenders 2010 and subsequent APP College of Policing MOSOVO Guidance , particularly with respect to PDPs .
” 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 proactive police information sharing to protect children from people convicted of violence or cruelty against a child
Wider context from the report “2. There appears to be a lacuna in pro-active information sharing practices by Police (similar to those found under Clare’s Law and Sarah’s Law) in order to protect children from those who may present a threat to them as a result of having previous convictions for violence/cruelty offences against a child - this concern is directed to the CEO College of Policing and the Chair of the NPCC.
” 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 Update and publish resources for health visitor- and school nurse-led services, emphasising family relationship and event chronology assessments for children with additional needs.
Verbatim wording from the response “Health visitors and school nurses as leaders of the Healthy Child Programme have a vital role in keeping children safe. They work with their teams and partners to support local safeguarding arrangements. We are currently updating a set of resources for health visitor and school nurse-led services. This includes emphasising the importance for children who may have additional needs to complete an assessment of family relationships and chronology of events to identify strengths and vulnerabilities. These are due to be published shortly.” 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 Police and Home Office matters were addressed directly by those bodies, so this response does not undertake further work on them.
Verbatim wording from the response “I am aware that the Police, as well as, the Home Office have responded to you directly on the relevant matters of concern. Therefore, this response focuses solely on your concern related to safeguarding assessments.” Source location Response from Department of Health and Social Care
Open published response
14 Sep 2022 Diane Margaret Austin-Martin · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of a mechanism for Social Services to be aware of vulnerable people's moves View source Loss of agency visibility of vulnerable people after initial contact View source Lack of a mechanism to ensure appropriate quality of privately arranged care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Diane Margaret Austin-Martin · 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
Diane Margaret Austin-Martin was a vulnerable adult with multiple sclerosis and significant care needs who was found severely underweight, with multiple pressure ulcers, in filthy and squalid living conditions on 22 March 2021. The report identified concerns about failures to notify Stockport Social Services of her move, the absence of adequate quality assurance for private care, and her becoming unseen by agencies after an initial benefits claim and GP visit.
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 mechanism for Social Services to be aware of vulnerable people's moves
Wider context from the report “1. The inquest heard evidence that there was no clear mechanism to ensure that Social Services were aware of her move despite her vulnerability having being identified whilst she resided in Northern Ireland. As a consequence Social Services were unsighted as to her being resident in Stockport;
” 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 Loss of agency visibility of vulnerable people after initial contact
Wider context from the report “4. After her initial claim for payment and her initial GP visit she dropped out of sight of agencies until she was found .
” 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 mechanism to ensure appropriate quality of privately arranged care
Wider context from the report “2. DWP were aware of her presence and payments were made recognising her needs but there was no mechanism to ensure that the care provided was of an appropriate quality ;
3. The inquest heard that where a private care arrangement exists as in this case there is no mechanism to ensure that the care is of a sufficient and appropriate quality in contrast to a resident of a care home;
” 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 Local authority safeguarding duties provide a mechanism to investigate private home-care arrangements where poor quality places an adult at risk.
Verbatim wording from the response “Adult safeguarding is relevant because local authorities have a duty, under the Care Act 2014, to make enquiries when they suspect that an adult with care and support needs is a) at risk of abuse or neglect and b) unable to protect themselves as a result of those needs. You were concerned that there is no mechanism to ensure that domiciliary care is of a sufficient and appropriate quality, in contrast to regulation of care homes. While it is correct that CQC does not inspect unregulated home care settings, local authority adult safeguarding duties do provide a mechanism by which to investigate private home care arrangements if the quality of care puts the cared-for person at risk of harm.” 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 Established GP registration processes, assessment, referrals and follow-up were considered appropriate for managing the patient’s long-term conditions.
Verbatim wording from the response “Your fourth and final concern noted that Ms Austin Martin dropped out of sight of agencies. NHS England has noted that there are robust processes in place across the Stockport GP population around the management of newly registered patients. The expectation is that following registration, an initial appointment will be offered to the patient which would include an assessment of medical needs, the prescribing of medications, and a plan agreed for how care will be managed moving forward and when any regular medications will be reviewed. The GP Practice where this patient was registered, have confirmed that Ms Austin-Martin was seen at a face-to-face consultation on 6th November 2019 shortly after registering on 30th October.” Source location Response from Department of health and Social Care
Open published response
14 Sep 2022 Irene Annie Davies · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Excessive waiting times for elective surgery View source Unavailability of ambulances for urgent responses 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
Irene Annie Davies · 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
Irene Annie Davies had multiple underlying health issues, including congestive cardiac failure and an infected nephrostomy associated with renal stones. After an accidental fall at home on 1 March 2022, she waited more than an hour for a Category 2 ambulance response, was taken to hospital, and was found unresponsive there on 2 March 2022. The substantive concerns included delays to renal stone surgery and delays in ambulance attendance due to service capacity and availability issues.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Excessive waiting times for elective surgery
Wider context from the report “1. The Inquest heard that Mrs Davies was identified as requiring surgery and the discomfort she was due to the renal stones and from the nephrostomy. Pre-COVID the wait time for surgery was 18 weeks. It had risen to 2 years at the time she required the surgery due to challenges in providing elective surgery during COVID . The Inquest heard that the Trust had been working to clear the backlog and reduce the waiting time but that it still stood at 12 months ;
” 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 ambulances for urgent responses
Wider context from the report “2. The evidence given to the Inquest was that after falling Mrs Davies needed an ambulance urgently - a Category 2 response. The Inquest heard that the wait for the ambulance was very distressing and arrived outside the target times due to ambulance availability in Greater Manchester at that time . The Inquest heard evidence that there was an ongoing issue of ambulance availability .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest an additional £3.3 billion in each of 2023–24 and 2024–25 to improve urgent and emergency care performance.
Verbatim wording from the response “As announced in the Autumn Statement, the government is investing an additional £3.3 billion in each of 2023-24 and 2024-25 to enable rapid action to improve urgent and emergency care performance towards pre-pandemic levels. The NHS will set out detailed recovery plans in the new year, including plans to improve Category 2 ambulance response times to 30 minutes.” 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 Open more than 50 additional surgical hubs to deliver almost two million extra routine operations by 2024–25.
Verbatim wording from the response “In August 2022, we confirmed that over 50 new hubs will open to deliver almost 2 million extra routine operations to reduce waiting lists over the next 3 years, meaning that over 140 surgical hubs will be open in England by 2024/25.” 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 Fund elective-care backlog recovery with more than £8 billion from 2022–23 to 2024–25.
Verbatim wording from the response “The NHS is working tirelessly to reduce the backlog of planned treatment. In February 2022, the NHS published its Delivery Plan for Tackling the COVID-19 Backlog of Elective Care.¹ The government plans to spend more than £8 billion from 2022-23 to 2024-25, in addition to the £2 billion Elective Recovery Fund and £700 million Targeted Investment Fund already made available to systems last financial year, to help drive up and protect elective activity.” 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 Invest £1.5 billion in surgical hubs and related elective-care recovery infrastructure.
Verbatim wording from the response “Furthermore, we have invested £1.5 billion in new surgical hubs and other investments to help elective surgical services recover. Elective surgical hubs are units that conduct planned procedures only and are often referred to as ‘cold sites’. They might exist within a hospital as a distinct unit or ringfenced theatre; or they might have been established on a separate site. They provide COVID-19-secure environments, with dedicated facilities bringing skills and resources together under one roof, with staff caring only for planned patients (who can be tested for COVID in advance) to minimise the risk of infection and reduce cancellations, enabling more patients to be seen. There are currently 92 elective surgical hubs that are operational across England.” Source location Response from Department of Health and Social Care
Open published response
12 Sep 2022 Delina Etienne · Prevention of Future Deaths report East London
View report summary
Concerns raised 7 Failure to ensure medical review of escalated chest pain View source Failure to assess inpatients for venous thromboembolism risk View source Failure to disclose the DNACPR error to investigating police officers View source Failure of nursing cardiac-arrest response to follow resuscitation guidelines View source Failure to record the DNACPR error in the incident report View source Failure to disclose the DNACPR error to the family under the Duty of Candour View source Failure to escalate episodes of raised blood pressure for medical review View source See 4 more concerns
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AI-generated summary
Delina Etienne · 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
Delina Etienne, who had schizo-affective disorder and was an inpatient receiving treatment, was found unresponsive in bed on 7 May 2021 and was declared deceased at the scene. The report identifies concerns about the chaotic response to her cardiac arrest, including failure to follow resuscitation procedures and an erroneous assumption that a DNACPR order was in place. It also identifies concerns about failures to escalate raised blood pressure and chest pain, assess VTE risk, and disclose the resuscitation error.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure medical review of escalated chest pain
Wider context from the report “4. An episode of chest pain identified by nursing staff on 21st April 2021 was escalated for medical review, no evidence of such a review exists .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to assess inpatients for venous thromboembolism risk
Wider context from the report “3. At no time during the two periods of Mrs Etienne’s inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy.
” 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 disclose the DNACPR error to investigating police officers
Wider context from the report “5. When nursing staff discovered that they had fallen into error by asserting that Mrs Etienne had a DNACPR in place the matter was discussed with ward management on the morning of 7th May 2022. Despite that, the error was not admitted ;
A. To officers of the Metropolitan Police who investigated the circumstances of the death that morning ,
B. To the Trust’s governance team – an incident report (DATIX) failed to mention the error,
C. To Mrs Etienne’s family who, subject to the Trust’s statutory “Duty of Candour” were communicated with by telephone and in person on 7th May 2021 and in written correspondence on 10th May 2021
” 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 nursing cardiac-arrest response to follow resuscitation guidelines
Wider context from the report “1. The response of the nursing team to a cardiac arrest was chaotic , and failed to follow trust and national guidelines designed to maximise the effectiveness of resuscitation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to record the DNACPR error in the incident report
Wider context from the report “5. When nursing staff discovered that they had fallen into error by asserting that Mrs Etienne had a DNACPR in place the matter was discussed with ward management on the morning of 7th May 2022. Despite that, the error was not admitted;
A. To officers of the Metropolitan Police who investigated the circumstances of the death that morning,
B. To the Trust’s governance team – an incident report (DATIX) failed to mention the error ,
C. To Mrs Etienne’s family who, subject to the Trust’s statutory “Duty of Candour” were communicated with by telephone and in person on 7th May 2021 and in written correspondence on 10th May 2021
” 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 disclose the DNACPR error to the family under the Duty of Candour
Wider context from the report “5. When nursing staff discovered that they had fallen into error by asserting that Mrs Etienne had a DNACPR in place the matter was discussed with ward management on the morning of 7th May 2022. Despite that, the error was not admitted ;
A. To officers of the Metropolitan Police who investigated the circumstances of the death that morning,
B. To the Trust’s governance team – an incident report (DATIX) failed to mention the error,
C. To Mrs Etienne’s family who, subject to the Trust’s statutory “Duty of Candour” were communicated with by telephone and in person on 7th May 2021 and in written correspondence on 10th May 2021
” 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 episodes of raised blood pressure for medical review
Wider context from the report “2. Whilst Mrs Etienne was an inpatient, the ward failed to escalate episodes of raised blood pressure for medical review in contravention of trust policy.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations