8 Jun 2022 Mr Ian McDonald Taylor · Prevention of Future Deaths report Inner South London
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Concerns raised 5 Failure to provide access to prescribed emergency inhaler medication during public-place police detention View source Failure to identify and address officer training or attitudinal deficits through supervision View source Failure to conduct and record an adequate ongoing risk assessment View source Failure to communicate detainee medical distress with appropriate urgency View source Unavailability of timely paramedic response during exceptional ambulance-service demand View source See 2 more concerns
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AI-generated summary
Mr Ian McDonald Taylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Ian McDonald Taylor suffered a cardiac arrest after a physical altercation while in police detention and died in hospital. Concerns included the police officer’s assessment and communication of Mr Taylor’s breathing difficulties, access to his inhaler while awaiting an ambulance, and the exceptionally delayed ambulance response.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide access to prescribed emergency inhaler medication during public-place police detention
Wider context from the report “Mr Taylor was in police detention in a public place and was known to be a sufferer of both COPD and asthma, required to take a regular combination of inhalers and had a history of emergency admission to hospital with life threatening asthma. He repeatedly asked urgently for his inhaler, which he said was in his pocket, and that he needed it and that he felt he was going to die. Police did not find it (although a broken inhaler found later at the scene might have been his). If he had been in a custody suite he would have had access to a custody nurse or medical practitioner who could have prescribed it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and address officer training or attitudinal deficits through supervision
Wider context from the report “In court he was asked if he had learnt any lessons from the incident and he did not acknowledge he had. He was asked if he would do anything different in future, he made excuses for his comments and he said that he would be more sensitive in future. He was not able to answer a question about what considerations should be made to form the view somebody did not need hospital. He did not accept that he had made an inadequate risk assessment. He did not accept that such comments could have or might in future contribute to death by indicating a lack of urgency to a sergeant not at the scene. He was given an opportunity to make any other comment and could not bring himself to apologize to the family.
There was no evidence heard in court of the content or effect of supervision of the officer after the incident or whether training or attitudinal deficits had been identified and addressed. The family are concerned as to whether the officer should be suspended pending further investigations, and I disclose that merely as a measure of their level of concern about public safety, as it is inappropriate for me to make any such recommendation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 conduct and record an adequate ongoing risk assessment
Wider context from the report “Whilst PC ████████ was away from Mr ████████ he accepts that he is heard shortly after 18.14 stating to his sergeant on the radio “He’s currently on the floor playing the whole poor me poor me; he’s going to have to go to hospital though as a matter of course.” And at 18.24: “He’s saying he has chest pains he cant breathe blah blah; it’s a load of nonsense but there we go”
He said in court that he formed these views as Mr Taylor seemed iller than he would expect from the nature of the previous altercation. He denied he thought Mr Taylor was faking. He claims to have made a continual risk assessment, but there is no record or evidence of that. He said that his views were influenced by a previous incident in which a man sprang to violence from previous calmness. They were not his final conclusion. There was no evidence as to his forming a different conclusion in the following 8 minutes before the cardiac arrest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate detainee medical distress with appropriate urgency
Wider context from the report “Whilst PC ████████ was away from Mr ████████ he accepts that he is heard shortly after 18.14 stating to his sergeant on the radio “He’s currently on the floor playing the whole poor me poor me; he’s going to have to go to hospital though as a matter of course.” And at 18.24: “He’s saying he has chest pains he cant breathe blah blah; it’s a load of nonsense but there we go”
He said in court that he formed these views as Mr Taylor seemed iller than he would expect from the nature of the previous altercation. He denied he thought Mr Taylor was faking. He claims to have made a continual risk assessment, but there is no record or evidence of that. He said that his views were influenced by a previous incident in which a man sprang to violence from previous calmness. They were not his final conclusion. There was no evidence as to his forming a different conclusion in the following 8 minutes before the cardiac arrest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of timely paramedic response during exceptional ambulance-service demand
Wider context from the report “Because of wholly exceptional demands on the ambulance service, a paramedic was not available until after he had suffered a cardio-respiratory arrest , from which he did not survive. A consultant paramedic and London Ambulance Service Director was asked about the feasibility of an inhaler device being available to police to offer to known asthmatics in exceptional circumstances when medical help was not available, such as is now in place in schools. He said that there were many difficulties: The difficulties included the adequacy of assessment of need by non medically trained persons on the scene, the difficulties of remote assessment, the threshold for confirmation of the person in distress being an established asthmatic, avoiding giving it to those with non asthmatic causes of breathlessness, and police training. Nevertheless he said that lives might be saved and it should be looked at. Advice was given to the court that such a proposal would need legislative change.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for considering police access to inhalers lies with the Home Office, with Department support.
Verbatim wording from the response “In terms of process for considering whether inhalers should be available to police officers, this would need to be undertaken by the Home Office (as the sponsor department for the police services) supported by the Department.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
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PFD Monitor interpretation MHRA owns the regulations governing non-prescribed police inhalers and must receive supporting evidence before legislative change can be considered.
Verbatim wording from the response “You may wish to note that allowing non-prescribed storage of salbutamol inhalers¹ by police officers will require a change in legislation - which in this case is the Human Medicines Regulations 2012. The Medicines and Healthcare products Regulatory Agency (MHRA) own these regulations, and will need to be presented with evidence that supports the case for making a change to the regulations.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 3 Unavailability of communication interpretation and advocacy support for callers with learning disabilities View source Lack of a procedure or specific protocol for callers with learning disabilities View source Failure of NHS Pathways triage to take account of callers with learning disabilities View source
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AI-generated summary
Daniel Robert Ludlam · 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 Robert Ludlam died at the scene on 30 December 2019 after an obstructed hiatus hernia caused gastrointestinal haemorrhage and hypovolemic shock. Concerns included that NHS Pathways triage did not specifically account for callers with learning disabilities, and that the absence of a suitable procedure could lead to incorrect triage or delays in sending paramedic support, particularly where no carer was available to assist communication.
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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 communication interpretation and advocacy support for callers with learning disabilities
Wider context from the report “(1) The NHS Pathways triage system for the calls that were made did not appear to take specific account of the patient who had a learning disability. Daniel could not communicate accurately his symptoms, and specifically would give the responses that he felt the call handler wanted to hear. He could not understand the questions being asked during the NHS Pathways triage.
(2) There appears to be no procedure or specific protocol in place to deal with a caller with learning disabilities, save for an early exit from the triage Pathway to request a clinician review. I am concerned that in similar future cases, either the information being given will not result in the correct triage category being reached, or any exit from the pathway to seek clinician input may result in a delay in sending out a paramedic crew.
(3) The carer assisting Daniel had to interpret the questions from the call handler in a way that Daniel could easily understand and then relay the responses back. In the future a call may come in from someone with learning disabilities who does not have a carer present to assist with the interpretation of the questions and to advocate on their behalf. Without there being a policy in place to deal with callers who cannot easily communicate or understand the questions, there is a risk of future death which could occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a procedure or specific protocol for callers with learning disabilities
Wider context from the report “(1) The NHS Pathways triage system for the calls that were made did not appear to take specific account of the patient who had a learning disability. Daniel could not communicate accurately his symptoms, and specifically would give the responses that he felt the call handler wanted to hear. He could not understand the questions being asked during the NHS Pathways triage.
(2) There appears to be no procedure or specific protocol in place to deal with a caller with learning disabilities , save for an early exit from the triage Pathway to request a clinician review. I am concerned that in similar future cases, either the information being given will not result in the correct triage category being reached, or any exit from the pathway to seek clinician input may result in a delay in sending out a paramedic crew .
(3) The carer assisting Daniel had to interpret the questions from the call handler in a way that Daniel could easily understand and then relay the responses back. In the future a call may come in from someone with learning disabilities who does not have a carer present to assist with the interpretation of the questions and to advocate on their behalf. Without there being a policy in place to deal with callers who cannot easily communicate or understand the questions, there is a risk of future death which could occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS Pathways triage to take account of callers with learning disabilities
Wider context from the report “(1) The NHS Pathways triage system for the calls that were made did not appear to take specific account of the patient who had a learning disability . Daniel could not communicate accurately his symptoms, and specifically would give the responses that he felt the call handler wanted to hear. He could not understand the questions being asked during the NHS Pathways triage.
(2) There appears to be no procedure or specific protocol in place to deal with a caller with learning disabilities, save for an early exit from the triage Pathway to request a clinician review. I am concerned that in similar future cases, either the information being given will not result in the correct triage category being reached, or any exit from the pathway to seek clinician input may result in a delay in sending out a paramedic crew.
(3) The carer assisting Daniel had to interpret the questions from the call handler in a way that Daniel could easily understand and then relay the responses back. In the future a call may come in from someone with learning disabilities who does not have a carer present to assist with the interpretation of the questions and to advocate on their behalf. Without there being a policy in place to deal with callers who cannot easily communicate or understand the questions, there is a risk of future death which could occur.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor NHS Pathways staff competency against the competency framework.
Verbatim wording from the response “With reference to your first concern around the system not taking into specific account of patients who have not been able to understand the questions asked, I would like to assure you that all health advisors and clinicians are trained on engaging with people with learning disabilities and this forms part of core training. NHS Pathways staff are monitored against the competency framework so staff competency is checked on an ongoing basis.” 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 Train health advisors and clinicians to engage appropriately with people with learning disabilities.
Verbatim wording from the response “With reference to your first concern around the system not taking into specific account of patients who have not been able to understand the questions asked, I would like to assure you that all health advisors and clinicians are trained on engaging with people with learning disabilities and this forms part of core training. NHS Pathways staff are monitored against the competency framework so staff competency is checked on an ongoing basis.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing NHS Pathways training, competency monitoring and adaptive triage, including clinician takeover, are considered sufficient for callers with learning disabilities.
Verbatim wording from the response “With reference to your first concern around the system not taking into specific account of patients who have not been able to understand the questions asked, I would like to assure you that all health advisors and clinicians are trained on engaging with people with learning disabilities and this forms part of core training. NHS Pathways staff are monitored against the competency framework so staff competency is checked on an ongoing basis.” Source location Response from Department of Health and Social Care
Open published response
26 May 2022 Katie Julia WILKINS · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 2 Unavailability of Haematologist capacity to address coagulopathy management needs View source Failure to provide Haematologist-led coagulopathy management for APML patients View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Katie Julia WILKINS · 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
Katie Julia WILKINS was a 14-year-old girl with acute promyelocytic leukaemia and associated coagulopathy who suffered a catastrophic intracerebral haemorrhage after fibrinogen concentrate was not administered in accordance with her treatment plan. She underwent decompressive surgery but did not recover and died on 31 July 2020. The principal concern was that management of coagulopathy in APML patients at Alder Hey Trust would continue to be led by Oncology Consultants rather than Haematologists, despite the serious bleeding risk.
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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 Haematologist capacity to address coagulopathy management needs
Wider context from the report “The inquest has highlighted an ongoing concern that Oncology Consultants will continue to be the lead Consultants for care of APML patients at Alder Hey Trust. The most significant risk of death in such patients is due to the risk of serious bleeding due to the associated and significant coagulopathy. Coagulopathy management should be led by a Haematologist to prevent future deaths due to this issue, that was recognised by a Consultant Haematologist who gave evidence to the inquest as a expert witness and as supported by a leading Haematologist at the Trust. There is a nationally a shortage of Haematologists which leaves Alder Hey Trust without resources available to them to address this matter of concern or to recruit .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Haematologist-led coagulopathy management for APML patients
Wider context from the report “The inquest has highlighted an ongoing concern that Oncology Consultants will continue to be the lead Consultants for care of APML patients at Alder Hey Trust . The most significant risk of death in such patients is due to the risk of serious bleeding due to the associated and significant coagulopathy. Coagulopathy management should be led by a Haematologist to prevent future deaths due to this issue, that was recognised by a Consultant Haematologist who gave evidence to the inquest as a expert witness and as supported by a leading Haematologist at the Trust. There is a nationally a shortage of Haematologists which leaves Alder Hey Trust without resources available to them to address this matter of concern or to recruit.
” 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 Review the distribution of medical specialty training posts and begin reallocating posts to support equitable workforce distribution.
Verbatim wording from the response “Turning to the concern regarding a shortage of haematologists, whilst we have made some progress, we know that there is more to do on staffing within haematology departments in England. In August 2022, there were 953 full time equivalent consultants working in the specialty of haematology in NHS hospital trusts in England, which is an increase of 342 (55.9%) since August 2010. However, Health Education England and NHS England are working collaboratively to review the distribution of medical specialty training posts across the country.” 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 Commission NHS England to develop a long-term workforce plan addressing workforce demand and supply.
Verbatim wording from the response “To support long-term workforce planning, the Department has commissioned Health Education England to produce a report looking at the long-term strategic drivers of workforce demand and supply. Building on this work, the Department has also commissioned NHS England to develop a long-term workforce plan. The plan will build on the foundations of the NHS People Plan. NHS England is due to complete this work by the end of 2022 and the key conclusions will be shared in due course.” 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 initiatives to improve retention, wellbeing and career progression for doctors in training, including flexible training opportunities.
Verbatim wording from the response “We are also taking action to increase the retention of doctors, including haematologists, and supporting them to progress into long-term careers. The Enhancing Junior Doctors’ Working Lives programme, led by Health Education England, is delivering a range of initiatives to improve the” 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 Analyse cancer call-for-evidence responses to develop a 10 Year Cancer Plan covering workforce requirements, including blood cancer.
Verbatim wording from the response “Finally, the Department is currently analysing the responses received to the cancer call for evidence to develop the forthcoming 10 Year Cancer Plan. It will set out plans to ensure that the appropriate workforce is in place to support all cancer patients and the plan will address all cancer types, including blood cancer. Diagnostic checks are a key part of many elective care pathways, including cancer. £2.3bn was awarded at SR21 to transform diagnostic services over the next three years, including for non-specific symptoms like those with potential blood cancer.” 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 Fund 1,500 additional undergraduate medical school places annually for domestic students in England.
Verbatim wording from the response “In addition to this, the Government has funded an additional 1,500 undergraduate medical school places each year for domestic students in England, a 25% increase over three years. The first graduates from this expansion entered foundation training in August this year. The Government is committed to ensuring that the number and distribution of medical school places are in line with England’s workforce requirements and continues to monitor the effectiveness of current arrangements.” 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 Establish eight additional haematology training places as part of cancer and diagnostic workforce investment.
Verbatim wording from the response “In addition, haematology has seen a moderate expansion as part of investment in the cancer and diagnostic workforce in the last two years. An additional eight training places have been established beginning in 2022. With current planning, an extra four places are expected to be created in 2023 and in 2024 as part of cancer and diagnostic workforce growth.” 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 Commission a report on the long-term strategic drivers of workforce demand and supply.
Verbatim wording from the response “To support long-term workforce planning, the Department has commissioned Health Education England to produce a report looking at the long-term strategic drivers of workforce demand and supply. Building on this work, the Department has also commissioned NHS England to develop a long-term workforce plan. The plan will build on the foundations of the NHS People Plan. NHS England is due to complete this work by the end of 2022 and the key conclusions will be shared in due course.” Source location Response from Department of Health and Social Care
Open published response
25 May 2022 Ian Michael Cockfield · Prevention of Future Deaths report East London
View report summary
Concerns raised 1 Failure to review falls risk assessments on arrival at a mental health ward 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
Ian Michael Cockfield · 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
Ian Michael Cockfield died in hospital on 12 July 2021 after collapsing and sustaining a cardiac arrest despite resuscitative efforts. The report raised concern that, after transfer to a mental health ward, his falls risk assessment was not reviewed and he subsequently fell while mobilising unsupervised, sustaining a serious head laceration.
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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 review falls risk assessments on arrival at a mental health ward
Wider context from the report “1. On Sunday 11th July 2021, Mr Cockfield was discharged from hospital after treatment. The patient was discharged to a mental health ward at a different hospital. Upon arrival at the mental health ward at 16.00hrs, a review of the patient’s falls risk assessment was not undertaken . The following day, Mr Cockfield suffered a fall whilst mobilising, unsupervised by staff. Mr Cockfield sustained a serious laceration to his head.
” Open source report
Concerns raised 12 Failure to ensure review of correspondence from TalkPlus View source Lack of guidance on thresholds for referral to secondary mental health services View source Failure to undertake mental health assessment and identify need for further or secondary mental health support View source Failure to document warnings about Mirtazepine side-effects and increased suicidal ideation risk View source Failure to confirm electronic letters are read and acted upon View source Prescribing of Mirtazepine without sufficient mental health prescribing competence View source Lack of ongoing mental health training for GPs View source Failure to offer face-to-face consultation or arrange follow-up View source Failure to ask about or document suicidal ideation and self-harm View source Failure to investigate and review deaths for learning and implementation of necessary changes View source Lack of prescribing policy for Mirtazapine, antidepressants and anxiolytics View source Failure to seek permission to involve partners and family in ongoing care View source See 9 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
Matthew John Evans · 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
Matthew John Evans was a 47-year-old man who developed insomnia, anxiety and depression during the third COVID-19 lockdown and died on 16 June 2021 after ending his life. The principal concerns related to the GP’s lack of mental-health assessment, suicide-risk assessment, follow-up and consideration of referral; the general practice’s prescribing, communication and clinical-governance arrangements; and TalkPlus’s lack of clear guidance on referral to secondary mental-health services.
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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 ensure review of correspondence from TalkPlus
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going 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 Lack of guidance on thresholds for referral to secondary mental health services
Wider context from the report “3. The actions of TalkPlus
There does not appear to be robust guidance or a policy as to the threshold necessary to refer a patient to secondary mental health services in Matthew’s circumstances where his mental health had deteriorated as the sessions progressed and he had began to indicate suicidal ideation and self-harm on a background of no previous mental health difficulties.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 mental health assessment and identify need for further or secondary mental health support
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going 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 document warnings about Mirtazepine side-effects and increased suicidal ideation risk
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going 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 confirm electronic letters are read and acted upon
Wider context from the report “2. The actions of the General Practice
No policy was provided to assist GP’s with prescribing of Mirtazapine and antidepressants and anxiolytics in general practice. There is no confirmation electronic letters have been signed as read and acted upon by the relevant GP. No evidence was provided with regard to ongoing training in mental health for GP’s. Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the practice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Prescribing of Mirtazepine without sufficient mental health prescribing competence
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going 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 Lack of ongoing mental health training for GPs
Wider context from the report “2. The actions of the General Practice
No policy was provided to assist GP’s with prescribing of Mirtazapine and antidepressants and anxiolytics in general practice. There is no confirmation electronic letters have been signed as read and acted upon by the relevant GP. No evidence was provided with regard to ongoing training in mental health for GP’s. Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the practice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to offer face-to-face consultation or arrange follow-up
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going 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 ask about or document suicidal ideation and self-harm
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going 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 investigate and review deaths for learning and implementation of necessary changes
Wider context from the report “2. The actions of the General Practice
No policy was provided to assist GP’s with prescribing of Mirtazapine and antidepressants and anxiolytics in general practice. There is no confirmation electronic letters have been signed as read and acted upon by the relevant GP. No evidence was provided with regard to ongoing training in mental health for GP’s. Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the practice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of prescribing policy for Mirtazapine, antidepressants and anxiolytics
Wider context from the report “2. The actions of the General Practice
No policy was provided to assist GP’s with prescribing of Mirtazapine and antidepressants and anxiolytics in general practice. There is no confirmation electronic letters have been signed as read and acted upon by the relevant GP. No evidence was provided with regard to ongoing training in mental health for GP’s. Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the practice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to seek permission to involve partners and family in ongoing care
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prescribing decisions are assigned to the responsible clinician, who must consider the patient’s needs, guidance and local commissioning decisions.
Verbatim wording from the response “You also raised concerns about the lack of policy to assist GPs with prescribing Mirtazapine, antidepressants and anxiolytics. The decision to prescribe a particular drug is a clinical one and should be based on the patient’s medical needs. Decisions about what medicines to prescribe are made by the doctor or healthcare professional responsible for that part of the patient’s care and prescribers are accountable for their prescribing decisions, both professionally and to their service commissioners. It is for the GP or other responsible clinician to work with their patient and decide on the course of treatment, with the provision of the most appropriate care for the individual always being the primary consideration.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing clinical guidance, professional standards, revalidation and training arrangements are considered sufficient to support appropriate prescribing and diagnosis.
Verbatim wording from the response “As noted by NHS England, there are several educational resources and guidance documents relating to the assessment and treatment of depression that are regularly reviewed and accessible to clinicians. These include National Institute for Health and Care Excellence (NICE) guidance, which details possible adverse effects of prescribing mirtazapine, Clinical Knowledge Summaries and the British National Formulary.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 13 Lack of guidance on placement of padded cot boards View source Delayed and incomplete serious incident investigations View source Failure to fully inform forensic pathology experts about relevant equipment involvement in a death View source Failure to accept and embed institutional learning from serious incidents View source Failure to preserve the scene and fully inform police and coronial investigators after a death View source Lack of regular direct visual supervision during the night View source Failure to inform the autopsy pathologist of the circumstances of a death View source Lack of openness, transparency and proper investigation of deaths View source Failure to provide yearly servicing of allocated cots View source Failure to provide accurate information to the CQC about a death View source Failure to undertake prompt internal enquiries after sudden unexpected deaths View source Failure to inform relevant statutory bodies of concerns after sudden unexpected deaths View source Failure to retain medical records after sudden unexpected deaths View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Connor Samuel Timothy Wellsted · 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
Connor Samuel Timothy Wellsted, a five-year-old boy with significant neuro-disabilities, was found deceased in his cot on 17 May 2017 during a residential neuro-rehabilitation stay. The investigation determined that he died following entrapment by a loose cot bumper causing airway obstruction. Concerns included inadequate cot maintenance and securing, lack of regular direct visual night-time supervision, and failures to preserve the scene, inform relevant bodies, and investigate the circumstances openly and transparently.
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 placement of padded cot boards
Wider context from the report “1. The cot
The cot Connor’s was allocated was nine years old, used infrequently and had not had a yearly servicing for the previous five years. There was no guidance or clarity as to how the padded boards/cot bumper should have been placed around the wooden frame of the cot in circumstances whereby the foster parents did not wish the cot to be padded.
It is likely the padded board (1m long, 40 cm wide with a soft side and a rigid side) was inappropriately and inaccurately placed on the wooden frame of the cot and as its top edge was without Velcro it could not have been attached to the cot leaving it loose with the result that it dislodged entrapping Connor across his neck.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delayed and incomplete serious incident investigations
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 fully inform forensic pathology experts about relevant equipment involvement in a death
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death .
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 accept and embed institutional learning from serious incidents
Wider context from the report “4. Senior management, Children’s Trust, Tadworth
The current senior management team have not acknowledged there was a lack of transparency and openness as to how Connor died, or that the Trust did not properly investigate his death or inform the relevant statutory bodies of the circumstances of his death giving rise to concern of an ongoing lack of insight that institutional learning around serious incidents has not been accepted by the Trust .
As a consequence, there is a need to introduce and develop robust clinical governance processes and systems to reassure the public and supervisory statutory bodies that they will be informed of any future adverse events and they will be investigated with openness, candour and transparency.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 preserve the scene and fully inform police and coronial investigators after a death
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 regular direct visual supervision during the night
Wider context from the report “2. Monitoring of Connor during the night:
Connor had no regular or direct visual supervision during the night (other than to open the door of his room to check if there was a smell) despite the request of his foster parent to check in circumstances whereby in other parts of the Trust regular visual inspection was the norm.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the autopsy pathologist of the circumstances of a death
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 openness, transparency and proper investigation of deaths
Wider context from the report “4. Senior management, Children’s Trust, Tadworth
The current senior management team have not acknowledged there was a lack of transparency and openness as to how Connor died , or that the Trust did not properly investigate his death or inform the relevant statutory bodies of the circumstances of his death giving rise to concern of an ongoing lack of insight that institutional learning around serious incidents has not been accepted by the Trust.
As a consequence, there is a need to introduce and develop robust clinical governance processes and systems to reassure the public and supervisory statutory bodies that they will be informed of any future adverse events and they will be investigated with openness, candour and transparency.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 yearly servicing of allocated cots
Wider context from the report “1. The cot
The cot Connor’s was allocated was nine years old, used infrequently and had not had a yearly servicing for the previous five years . There was no guidance or clarity as to how the padded boards/cot bumper should have been placed around the wooden frame of the cot in circumstances whereby the foster parents did not wish the cot to be padded.
It is likely the padded board (1m long, 40 cm wide with a soft side and a rigid side) was inappropriately and inaccurately placed on the wooden frame of the cot and as its top edge was without Velcro it could not have been attached to the cot leaving it loose with the result that it dislodged entrapping Connor across his neck.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 accurate information to the CQC about a death
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death .
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 prompt internal enquiries after sudden unexpected deaths
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns . Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to inform relevant statutory bodies of concerns after sudden unexpected deaths
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns . Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 medical records after sudden unexpected deaths
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns . Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” Open source report
12 May 2022 Sarah Louise Dunn · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 2 Inadequate training and awareness of sepsis risk following Early Medical Abortion View source Failure to consider and initiate sepsis protocols following Early Medical Abortion View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sarah Louise Dunn · 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
Sarah Louise Dunn developed Group A Streptococcus sepsis following an early medical abortion and died in hospital on 11 April 2020 after progressing to toxic shock. The report identified failures to recognise and treat sepsis across primary and secondary care, including delays in assessment, use of sepsis pathways and antibiotics. The principal concern was inadequate awareness and training regarding the risk of sepsis following early medical abortion, creating a risk of avoidable future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate training and awareness of sepsis risk following Early Medical Abortion
Wider context from the report “(1) Inadequate training of doctors and other medical professionals re the risk of sepsis following Early Medical Terminations.
Evidence from a wide range of clinicians who had cared for Sarah in March and April 2020 echoed each other. The clinician evidence revealed a common theme of lack of training, knowledge or experience on the part of physicians and medical staff (including GPs, pharmacist and acute hospital doctors) regarding the rare risk of sepsis following Early Medical Termination. The hospital trust accepted that at the time of Sarah’s death, there was confirmation bias in their thinking due to the Covid 19 pandemic and that other differential diagnosis were not considered in this case.
Whilst the witness evidence was that Sepsis protocols were in place at both the GP surgery and the hospital trust, what is of particular concern is that none of the professionals who saw or spoke to Sarah were considering Sepsis in this case. Sarah was spoken to and seen by numerous medical professionals in both primary and secondary care but no sepsis protocols were initiated and I found that the compounding delays in screening, diagnosis and treatment more than minimally contributed to a poor outcome in Sarah’s case.
I heard evidence that Sepsis remains a diagnostic challenge despite all the guidelines available because the same infection does not always present in the same way in different individuals, symptoms may be non-specific and the Emergency Department may not have an obvious specific source of infection that physicians can identify. In addition, in younger patients such as Sarah, their physiological reserve and ability to cope with the infection can mean that their circulatory collapse and deterioration of the NEWS score occurs later in the disease process. Having said that, I am concerned that there remains a lack of awareness of sepsis in particular following Early Medical Abortion given how many opportunities there were to think sepsis in this case. Whilst those giving evidence to me in court are now aware of sepsis and the risks post abortion having reflected on Sarah’s death, I am concerned that there is a lack of awareness of the risk of sepsis following Early Medical Abortions . This lack of awareness in my view risks avoidable 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 consider and initiate sepsis protocols following Early Medical Abortion
Wider context from the report “(1) Inadequate training of doctors and other medical professionals re the risk of sepsis following Early Medical Terminations.
Evidence from a wide range of clinicians who had cared for Sarah in March and April 2020 echoed each other. The clinician evidence revealed a common theme of lack of training, knowledge or experience on the part of physicians and medical staff (including GPs, pharmacist and acute hospital doctors) regarding the rare risk of sepsis following Early Medical Termination. The hospital trust accepted that at the time of Sarah’s death, there was confirmation bias in their thinking due to the Covid 19 pandemic and that other differential diagnosis were not considered in this case.
Whilst the witness evidence was that Sepsis protocols were in place at both the GP surgery and the hospital trust, what is of particular concern is that none of the professionals who saw or spoke to Sarah were considering Sepsis in this case . Sarah was spoken to and seen by numerous medical professionals in both primary and secondary care but no sepsis protocols were initiated and I found that the compounding delays in screening, diagnosis and treatment more than minimally contributed to a poor outcome in Sarah’s case.
I heard evidence that Sepsis remains a diagnostic challenge despite all the guidelines available because the same infection does not always present in the same way in different individuals, symptoms may be non-specific and the Emergency Department may not have an obvious specific source of infection that physicians can identify. In addition, in younger patients such as Sarah, their physiological reserve and ability to cope with the infection can mean that their circulatory collapse and deterioration of the NEWS score occurs later in the disease process. Having said that, I am concerned that there remains a lack of awareness of sepsis in particular following Early Medical Abortion given how many opportunities there were to think sepsis in this case. Whilst those giving evidence to me in court are now aware of sepsis and the risks post abortion having reflected on Sarah’s death, I am concerned that there is a lack of awareness of the risk of sepsis following Early Medical Abortions. This lack of awareness in my view risks avoidable future deaths.
” 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 NHS England to ensure adherence to national guidance for detecting and managing sepsis-related deterioration.
Verbatim wording from the response “The Department is working closely with NHS England to ensure adherence to national guidance that supports the detection and management of deterioration from sepsis. In addition, in April 2022, NHS England launched a Commissioning for Quality and Innovation scheme for ‘Recording of NEWS2 score, escalation and response time for unplanned critical care admissions’. This measure will incentivise providers of acute care to use NEWS2, ensuring adherence to evidence-based steps in the identification and recording of deterioration, and enabling swifter response in acute settings.” Source location 2022-0144 - Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Relevant medical Royal Colleges set postgraduate trainee doctors’ curricula, subject to standards set by the General Medical Council.
Verbatim wording from the response “You may also wish to know that the training curricula for postgraduate trainee doctors is set by the relevant medical Royal College and has to meet the standards set by the GMC. Whilst curricula do not necessarily highlight specific conditions for doctors to be aware of, they instead emphasise the skills and approaches that a doctor must develop to ensure accurate and timely diagnoses and treatment plans for their patients. This is essential in promoting effective learning and preventing future deaths or serious harm occurring again.” Source location 2022-0144 - 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 General practitioners are responsible for maintaining current clinical knowledge and identifying learning needs through continuing professional development.
Verbatim wording from the response “Further to this, General Practitioners are responsible for ensuring their own clinical knowledge remains up-to-date and for identifying learning needs as part of their continuing professional development. This activity should include taking account of new research and developments in guidance, such as that produced by the National Institute for Health and Care Excellence, to ensure that they can continue to provide high quality care to all patients. All UK registered doctors are expected to meet the professional standards set out in the General Medical Council (GMC)’s Good Medical Practice. In 2012, the GMC introduced revalidation which supports doctors in regularly reflecting on how they can develop or improve their practice, gives patients confidence doctors are up to date with their practice, and promotes improved quality of care by driving improvements in clinical governance.” Source location 2022-0144 - Response from Department of Health and Social Care
Open published response
12 May 2022 Joan Hoggett · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 4 Insufficient staffing capacity to cover required engagement work View source Failure to act upon information provided by the perpetrator’s family View source Failure to share relevant information with the perpetrator’s family View source Failure to take available opportunities for proactive engagement with the perpetrator 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
Joan Hoggett · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joan Hoggett died in Sunderland Royal Hospital on 5 September 2018 after being attacked and stabbed multiple times at her place of work. Concerns included insufficient engagement by the Mental Health Trust with the perpetrator’s family, missed opportunities for more proactive engagement, and challenges associated with staff capacity and absence.
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 staffing capacity to cover required engagement work
Wider context from the report “1. The family of the perpetrator were not as engaged by the Trust as much as they could have been in terms of:
- sharing information with them; and
- acting upon information provided by them.
I acknowledge that this must take into account the Service User’s capacity and consent and also respecting confidentiality, but in this case these matters did not seem to be an issue.
2. A more proactive approach may have been appropriate.
I am concerned that the opportunities to engage more were not taken.
Engagement with the perpetrator was influenced to some extent by the capacity of the Mental Health Trust and its personnel to meet the competing demands of the Service with the resources at their disposal . This was more challenging at times of staff absence and the ability of the Trust to sufficiently cover the work needed with the perpetrator and 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 act upon information provided by the perpetrator’s family
Wider context from the report “1. The family of the perpetrator were not as engaged by the Trust as much as they could have been in terms of:
- sharing information with them; and
- acting upon information provided by them.
I acknowledge that this must take into account the Service User’s capacity and consent and also respecting confidentiality, but in this case these matters did not seem to be an issue.
2. A more proactive approach may have been appropriate.
I am concerned that the opportunities to engage more were not taken.
Engagement with the perpetrator was influenced to some extent by the capacity of the Mental Health Trust and its personnel to meet the competing demands of the Service with the resources at their disposal. This was more challenging at times of staff absence and the ability of the Trust to sufficiently cover the work needed with the perpetrator and 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 share relevant information with the perpetrator’s family
Wider context from the report “1. The family of the perpetrator were not as engaged by the Trust as much as they could have been in terms of:
- sharing information with them ; and
- acting upon information provided by them.
I acknowledge that this must take into account the Service User’s capacity and consent and also respecting confidentiality, but in this case these matters did not seem to be an issue.
2. A more proactive approach may have been appropriate.
I am concerned that the opportunities to engage more were not taken.
Engagement with the perpetrator was influenced to some extent by the capacity of the Mental Health Trust and its personnel to meet the competing demands of the Service with the resources at their disposal. This was more challenging at times of staff absence and the ability of the Trust to sufficiently cover the work needed with the perpetrator and 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 take available opportunities for proactive engagement with the perpetrator
Wider context from the report “1. The family of the perpetrator were not as engaged by the Trust as much as they could have been in terms of:
- sharing information with them; and
- acting upon information provided by them.
I acknowledge that this must take into account the Service User’s capacity and consent and also respecting confidentiality, but in this case these matters did not seem to be an issue.
2. A more proactive approach may have been appropriate.
I am concerned that the opportunities to engage more were not taken.
Engagement with the perpetrator was influenced to some extent by the capacity of the Mental Health Trust and its personnel to meet the competing demands of the Service with the resources at their disposal. This was more challenging at times of staff absence and the ability of the Trust to sufficiently cover the work needed with the perpetrator and others.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase the NHS mental health workforce to expand service capacity and support safer care delivery.
Verbatim wording from the response “You may wish to know that the mental health workforce increased by 5,900 full-time equivalent staff in December 2021 compared to December 2020, and by over 11,800 compared to December 2010. We know there is more to do to ensure we have sufficient numbers of healthcare staff to deliver our aims for high quality, accessible mental health services. Our aim, as set out in the Mental Health Implementation Plan, is to expand the mental health workforce by an additional 27,000 healthcare professionals by 2023/24 (compared to 2019/20).” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest at least £2.3 billion annually to expand and transform NHS mental health services and increase treatment capacity.
Verbatim wording from the response “To enable this increase in workforce, through the NHS Long Term Plan, we are investing at least £2.3 billion additional funding a year from 2019/20 to expand and transform mental health services in England by 2023/24. This will enable an extra two million people to be treated by NHS mental health services by 2023/24. This includes new integrated community models for adults with severe” 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 Responsibility for hospital staffing and operations lies with the relevant NHS Trust.
Verbatim wording from the response “You raised concerns about the capacity of the Mental Health Trust, and its workforce, to engage with the perpetrator and to meet the competing demands of the service within the resources at its disposal. Responsibility for the staffing and operations of a hospital lies with the relevant Trust. However, the Department does recognise the need to increase capacity in NHS mental health services due to the increasing demand for services.” Source location Response from Department of Health and Social Care
Open published response
3 May 2022 Kate Hedges · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to provide consistently trauma-informed mental health services to people who have experienced trauma View source Failure to follow safeguarding policy after disclosure of a serious allegation of inappropriate touching by another patient View source Failure to ensure staff undertaking risk assessments and formulating care plans have access to all relevant information View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kate Hedges · 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
Kate Hedges died at Gatley Station on 27 November 2020 as a consequence of injuries sustained in an event that is redacted in the supplied text. The concerns included separate computerised record-keeping systems that could mean staff lacked relevant information for risk assessments and care plans, and an alleged failure to follow safeguarding policy. The report also raised concerns that mental health services were not consistently trauma-informed and that the ward environment could be distressing and difficult for people who had experienced trauma.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consistently trauma-informed mental health services to people who have experienced trauma
Wider context from the report “1. The court heard evidence to the effect that Ms Hedges often found the environment of a (mixed-sex) mental health ward distressing and difficult, both as a result of her illness and the ongoing effects of traumatic experiences endured at various stages of her life.
It is a matter of concern that modern mental health service design and provision is not consistently or sufficiently trauma-informed , with services being delivered to people such as Ms Hedges who have experienced trauma in a way which is likely to cause a patient to feel unsafe and excluded , thus undermining goals for treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to follow safeguarding policy after disclosure of a serious allegation of inappropriate touching by another patient
Wider context from the report “2. It is also a matter of concern that, following disclosure by Ms Hedges at a multidisciplinary meeting of a serious allegation to the effect that she was touched inappropriately by another patient, the Trust’s own safeguarding policy was not followed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff undertaking risk assessments and formulating care plans have access to all relevant information
Wider context from the report “1. The court heard evidence that the Trust’s Psychological Therapy serviced used (and continues to use) a different computerised record-keeping system from that used by staff providing acute mental health services, which the latter staff group do not necessarily have access to . It is a matter of concern that this approach means staff undertaking risk assessments and formulating care plans may on occasion be doing so without access to all relevant information . This was certainly true in Ms Hedges’ case.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replace mental health estate dormitories with single, ensuite bedrooms through a multi-year capital programme.
Verbatim wording from the response “We have committed over £400m for a multi-year capital programme to replace dormitories in the mental health estate with single, ensuite bedrooms by 2023/24. By 2024/25, over 1200 beds in mental health dormitories across more than 50 sites will be replaced with single, en suite rooms. Although this may impact bed availability temporarily, it will support patients by improving their care, safety and sense of dignity.” Source location Response from Department of Health and Social Care
Open published response
28 Apr 2022 Susan Elizabeth Carling · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Suicides among health service professionals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Susan Elizabeth Carling · 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
Susan Elizabeth Carling, a General Practitioner, died by suicide at her home address on 2 January 2022. The report raises concern about suicide among health-service professionals and the need to highlight available support for GPs and this vulnerable professional group.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Suicides among health service professionals
Wider context from the report “Her family brought to my attention that there are approximately 100 people in the health service who commit suicide each year . They requested that in my role to prevent future deaths that this is considered by someone who could potentially take action to prevent future deaths in this profession going forward.
I am aware and made it clear to the family that there are organisations that GP’s can access for support however they like I agree that this needs to be highlighted if suicides are to be prevented in this vulnerable professional group .
” 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 Invest an additional £57 million in suicide prevention through the NHS Long Term Plan, supporting local prevention plans and bereavement services.
Verbatim wording from the response “More generally, we are investing an additional £57million in suicide prevention by 2023/24 through the NHS Long Term Plan. Through this, all areas of the country are seeing investment to support local suicide prevention plans and the development of suicide bereavement services.” 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 more than £45 million to continue healthcare staff wellbeing support, including mental health hubs providing outreach and assessment services.
Verbatim wording from the response “Finally, over £45 million has been invested in 2022/23 to support the continuation of the health and wellbeing support offer for healthcare staff, which includes the 40 mental health hubs across the country that provide outreach and assessment services. This helps frontline staff receive rapid access to evidence-based mental health services. NHS England continue to develop tailored health and wellbeing offers that meet the needs of their local workforce, especially through the Mental Health Hubs in each Integrated Care System and through occupational health services that are being supported through the national Growing Occupational Health and Wellbeing programme.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 10 Lack of multidisciplinary clinical assessment and formulation addressing autism View source Gap in acute and crisis mental health support alongside commissioned autism care View source Lack of local specialist autism assessment and adapted psychological therapy View source Failure to understand autism-related trauma in risk assessment View source Failure to respond promptly to distress and remove discounted diagnostic references View source Failure of communication and shared information across autism and mental health teams View source Failure to make timely reasonable sensory and environmental adjustments View source Failure to provide a care coordinator and effective care plan View source Lack of person-centred autism-informed holistic care planning View source Failure to avoid attributing an undiagnosed personality disorder to an autistic patient View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Zoe Emma ZAREMBA · 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
Zoe Emma ZAREMBA, who had a history of repeated self-harm and suicide attempts, ingested an unknown quantity of a substance after going missing from home and was found unresponsive on 21 June 2020; her death was established as resulting from the ingestion. The report identified concerns about clinicians’ failure to understand and adapt care to her autism, the unsubstantiated attribution of Emotionally Unstable Personality Disorder, inadequate coordinated mental health support, and the absence of effective care planning and risk assessment.
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 multidisciplinary clinical assessment and formulation addressing autism
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism ;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Gap in acute and crisis mental health support alongside commissioned autism care
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of local specialist autism assessment and adapted psychological therapy
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy . Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 understand autism-related trauma in risk assessment
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe .
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to respond promptly to distress and remove discounted diagnostic references
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution . There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 communication and shared information across autism and mental health teams
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working , that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to make timely reasonable sensory and environmental adjustments
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all ;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a care coordinator and effective care plan
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 person-centred autism-informed holistic care planning
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender . As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 avoid attributing an undiagnosed personality disorder to an autistic patient
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”) .
3 That attribution was not formally diagnosed , and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” 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 Implement the National Autism Strategy while considering effective mechanisms, including empowering local systems to improve outcomes.
Verbatim wording from the response “You may also wish to know that, on 21 July 2021, we published the refreshed National Autism Strategy, which aims to improve the lives of autistic people by addressing health inequalities and improving access to public services.² Actions within the strategy include improving health and care professionals’ understanding of autism. We remain committed to implementing the strategy and are considering the most effective mechanisms to achieve this, including empowering local systems to deliver improved outcomes for autistic people.” 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 Require registered providers to ensure staff receive role-appropriate learning disability and autism training.
Verbatim wording from the response “We know that having the right workforce with the right skills and training to support autistic people is crucial in ensuring a person receives safe and appropriate care and support. This is why, from 1 July 2022, registered providers are required to ensure their staff receive specific training on learning disability and autism appropriate to their role.” 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 £40 million to improve seven-day specialist multidisciplinary and crisis support capacity for autistic people and people with learning disabilities.
Verbatim wording from the response “You raised the importance of community provision. In 2022/2023, we are investing £70 million to prevent avoidable admissions and improve community support for autistic people and people with a learning disability. This includes £40 million to improve the capacity and capability of 7-day specialist multidisciplinary and crisis support for autistic people and people with a learning disability in every area of the country. Additionally, £30 million has been committed for keyworker services for autistic children and young people and children and young people with a learning disability with the most complex needs at risk of being admitted to mental health settings or who are inpatients.” Source location Response from Department of Health and Social Care
Open published response
22 Apr 2022 JOHN SCOTT MURPHY · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Delays in ambulances clearing Accident and Emergency departments View source Delays in paramedic attendance at Category 2 calls View source Shortages of ambulance staff and emergency vehicles View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
JOHN SCOTT MURPHY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Scott Murphy, who had recently tested positive for Covid-19, deteriorated while alone at home and called the ambulance service at 03:20 on 11 July 2021. An ambulance arrived at 05:21, by which time he had died; the inquest concluded that the death was from natural causes, with Covid-19 pneumonitis and hypertensive heart disease recorded. The substantive concerns were delays in paramedics attending Category 2 calls due to staff and vehicle shortages, and ambulances being delayed at Accident and Emergency departments.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulances clearing Accident and Emergency departments
Wider context from the report “(2) The resources available in the North West Ambulance Service cannot be fully utilised because of the delays in ambulances clearing Accident and Emergency departments caused by the pressure on these departments across the NHS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 paramedic attendance at Category 2 calls
Wider context from the report “(1) Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges because there are residual staff and emergency vehicle shortages.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Shortages of ambulance staff and emergency vehicles
Wider context from the report “(1) Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges because there are residual staff and emergency vehicle shortages .
” Open source report
22 Apr 2022 Matthew Alexander CASEBY · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 7 Failure to maintain a single consistent patient record View source Failure of serious incident investigations to identify and implement critical lessons View source Inaccuracies in clinical records View source Failure to complete and update risk assessments in a timely manner by suitably experienced staff View source Unsafe courtyard layout for patient restraint View source Unsafe courtyard perimeter fence for preventing absconding and ligature risk View source Lack of standard guidelines for perimeter fences and security in acute mental health unit outside areas View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Matthew Alexander CASEBY · 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
Matthew Caseby was detained under the Mental Health Act after being found on railway lines and in a school playground, and was transferred to the Priory Hospital in Birmingham. He absconded from the hospital courtyard on 7 September 2020 after being left unattended, and was fatally injured after stepping in front of a train on 8 September 2020. The principal concerns included inadequate recording and communication of absconding risks, failure to update risk assessments, lack of a courtyard observation policy and risk assessment, and inadequate courtyard safety.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a single consistent patient record
Wider context from the report “1. Record keeping: During the inquest staff confirmed that they record information about patients in two ways. On the electronic records and on handwritten handover sheets. During the inquest the evidence confirmed that different information was recorded on each. I have serious concerns that staff are recording information in two places and this creates a real risk, as materialised in Matthew’s case, that different information is recorded in each place and key information gets lost .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 identify and implement critical lessons
Wider context from the report “4. Serious Incidents: The inquest heard evidence that a previous absconsion over the courtyard fence in October 2019 had not prompted any review of the height of the fence and focussed on why the patient absconded to have a cigarette. I have serious concerns that the system of investigation in place at the Priory means critical lessons are not learnt at the appropriate time .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inaccuracies in clinical records
Wider context from the report “2. Record Keeping quality: There were numerous inaccuracies in Matthew’s medical records , eg his status was written as informal when he was formal, he was described as violent when he was not and was described as "she". Staff were unable to explain how that occurred. The investigation witness from the Priory thought there was an element of cutting and pasting into the records from another patient’s records. I have serious concerns about the accuracy of the clinical record at the Priory for what are some of the most vulnerable patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and update risk assessments in a timely manner by suitably experienced staff
Wider context from the report “3. Risk Assessments: The inquest heard how all members of staff can update a Risk Assesment at any time. Despite this, and with clear evidence that Matthew was at risk of absconsion, his risk assessment was not updated over the weekend when the risk materialised . I have serious concerns about how risk assessments are completed, when they are completed, who completes them and whether they are updated in a timely and necessary manner by suitably experienced staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unsafe courtyard layout for patient restraint
Wider context from the report “5. Courtyard Fence: A patient absconded over the courtyard fence during the inquest which indicates the courtyard area is not safe. I have serious concerns that an urgent review of the courtyard is required. In addition, I heard evidence from Dr ████████ that the fence was a ligature risk. Staff gave evidence that the courtyard in its current format with steps and a gradient on the grass bank was unsafe especially if a patient needed to be restrained .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unsafe courtyard perimeter fence for preventing absconding and ligature risk
Wider context from the report “5. Courtyard Fence: A patient absconded over the courtyard fence during the inquest which indicates the courtyard area is not safe . I have serious concerns that an urgent review of the courtyard is required. In addition, I heard evidence from Dr ████████ that the fence was a ligature risk . Staff gave evidence that the courtyard in its current format with steps and a gradient on the grass bank was unsafe especially if a patient needed to be restrained.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 standard guidelines for perimeter fences and security in acute mental health unit outside areas
Wider context from the report “For the Department of Health
1. National guidelines for perimeter fences and security in acute mental health unit outside areas. The inquest heard evidence from Professor ████████, a specialist in safety in Mental Health settings, that it would be useful for there to be standard guidelines for the requirements of perimeter fences and security for outside areas in acute Mental Health units as no such guidance is in place . This would ensure the correct level of security for some of the most vulnerable patients whilst maintaining a therapeutic setting.
” 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 Investigate national guidelines for perimeter fences and security in acute mental health unit outside areas by collecting data and reviewing evidence and patient and family feedback.
Verbatim wording from the response “I have asked my officials to look into your recommendation for national guidelines for perimeter fences and security in acute mental health unit outside areas. They will collect data on ward perimeters and review the evidence base and patient and family feedback.” Source location Response from Gillian Keegan MP
Open published response
6 Apr 2022 Oliver Christopher Lindsay · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to ensure widespread understanding of the risks of fetal growth restriction View source Delays in providing urgently required fetal growth scans 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
Oliver Christopher Lindsay · 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
Oliver Christopher Lindsay was identified as having fetal growth restriction before suffering an unexpected placental abruption at home on 6 September 2020. He was born with ambulance support, received advanced paediatric life support, and was transferred to hospital, where he was found to have a severe hypoxic brain injury and died on 12 September 2020. The principal concerns were delays in obtaining a growth scan because of scanning capacity issues and limited understanding of the risks associated with fetal growth restriction.
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 widespread understanding of the risks of fetal growth restriction
Wider context from the report “2. The inquest heard evidence from a number of obstetricians about the very significant risks fetal growth restriction presented to the health of a baby. There was clear evidence that the risks of fetal growth restriction were not widely understood outside experienced obstetric professionals and that greater understanding and clarity of the risks was important in helping all those involved. This was particularly true in relation to parents faced with a sudden change at a difficult time. It was suggested during the inquest that as part of the Saving Babies bundle a FAQ sheet should be developed for parents which set out what fetal growth restriction is ; the risks it presented to a baby at various stages of a pregnancy and the national guidance to reduce risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in providing urgently required fetal growth scans
Wider context from the report “1. At his mother’s midwife check-up, it was identified that Oliver may have fetal growth restriction and that a scan was urgently required. A referral was made to the acute trust. However scanning capacity issues meant that there was a delay in an appointment being offered. Oliver’s parents were very concerned and felt they had no choice but to pay to have a private scan which did confirm fetal growth restriction and resulted in his mother attending the acute trust to be seen. The inquest heard evidence that there were capacity issues in relation to growth scans nationally particularly after a bank holiday or a weekend.
” Open source report
Concerns raised 1 Delays in transferring GP medical notes between practices View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Fadzai CHITAKUNYE · 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
Fadzai Chitakunye died at Leicester Royal Infirmary on 26 February 2019 from a haemorrhage into her brain tumour. The report also records progression of hepatitis B infection following chemotherapy. A principal concern was the delay in transferring GP records, which may result in important medical history being missed, including hepatitis B information relevant to her treatment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring GP medical notes between practices
Wider context from the report “In this case the transfer of the notes from the deceased’s Nottingham general practitioner to the Leicestershire general practitioner took 11 months as reported to me by the GP. She also reports that notes still take about 16 weeks to be transferred between GP’s . Important information about the patient’s medical history may be missed particularly if the patient is not able to communicate effectively with the new GP .
” 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 Invest in technology to improve patient care through the General Practice Forward View.
Verbatim wording from the response “General practice is the cornerstone of our NHS and Government is committed to helping staff deliver for patients. The 2016 General Practice Forward View¹ strategy provided support for practices to build the capacity and capabilities required to meet patients’ needs. As part of the GP Forward View, a key aspect included investment in technology to improve patient care and work to increase the electronic transfer of records between practices.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase electronic transfer of health records between general practices through the General Practice Forward View.
Verbatim wording from the response “General practice is the cornerstone of our NHS and Government is committed to helping staff deliver for patients. The 2016 General Practice Forward View¹ strategy provided support for practices to build the capacity and capabilities required to meet patients’ needs. As part of the GP Forward View, a key aspect included investment in technology to improve patient care and work to increase the electronic transfer of records between practices.” Source location Response from Department of Health and Social Care
Open published response
28 Mar 2022 Hayley Smith · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 2 Failure to share crucial clinical information between healthcare organisations View source Failure of separate clinical record systems to provide cross-organisational access to crucial information 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
Hayley Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Hayley Smith developed severe and enduring anorexia nervosa and died on 29 December 2019 after an out-of-hospital cardiac arrest caused by severe hypoglycaemia. The inquest identified inadequate communication and information-sharing between the organisations involved in her care, including failures to share information about her Community Treatment Order.
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 share crucial clinical information between healthcare organisations
Wider context from the report “(1) Evidence given at the inquest revealed that there were seven different organisations involved in Hayley’s care all of whom had different systems for recording their clinical notes:
I. South London and the Maudsley NHS Foundation Trust (SLAM)
II. North East London NHS Foundation Trust (NELFT locally known as the Kent and Medway Eating Disorders Team)
III. The White House
IV. Kings College NHS Foundation Trust (Kings)
V. General Practitioner (GP)
VI. East Kent Hospitals NHS Trust (EKHT for Queen Elizabeth the Queen Mother)
VII. South East Coast Ambulance Service
(2) The evidence given at the inquest revealed that each of the organisations were reliant on being copied into correspondence or on specific information being shared by others . The White House were not sent copies of clinical correspondence and at the time did not have access to GP records although since Hayley’s death do now have access to GP records. The mental health team at NELFT were responsible for managing Hayley’s CTO despite the fact that she was placed out of their geographical area but were not aware she had been seen by either the ambulance service or by Queen Elizabeth the Queen Mother hospital.
(3) The evidence at the inquest revealed that communication between those involved in her short life was inadequate and, as each ran separate clinical records systems, they could not access crucial information which could have made a difference ultimately meaning Hayley may not have died when she did. It is highly likely that the paramedic at South East Coast Ambulance Trust who attended Hayley on 23rd December or the emergency department nurse who saw her at Queen Elizabeth the Queen Mother hospital on 24th December 2019 been aware that Hayley was on a CTO they or her treating mental health team would have been able to take steps which would have saved her life.
(4) Evidence was given at the inquest that locally some steps have been taken to try to share key data between acute hospitals but there have been significant hurdles which have impeded the process namely, the different information technology systems used, licensing issues for the software, Data Protection requirements, confidentiality and consent issues as well as training and funding.
(5) Hayley died following an out of hospital cardiac arrest on Christmas day 2019. If information been shared between different health care organisations particularly crucial information about Hayley’s CTO it is highly likely she would still be alive today.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 separate clinical record systems to provide cross-organisational access to crucial information
Wider context from the report “(1) Evidence given at the inquest revealed that there were seven different organisations involved in Hayley’s care all of whom had different systems for recording their clinical notes :
I. South London and the Maudsley NHS Foundation Trust (SLAM)
II. North East London NHS Foundation Trust (NELFT locally known as the Kent and Medway Eating Disorders Team)
III. The White House
IV. Kings College NHS Foundation Trust (Kings)
V. General Practitioner (GP)
VI. East Kent Hospitals NHS Trust (EKHT for Queen Elizabeth the Queen Mother)
VII. South East Coast Ambulance Service
(2) The evidence given at the inquest revealed that each of the organisations were reliant on being copied into correspondence or on specific information being shared by others. The White House were not sent copies of clinical correspondence and at the time did not have access to GP records although since Hayley’s death do now have access to GP records. The mental health team at NELFT were responsible for managing Hayley’s CTO despite the fact that she was placed out of their geographical area but were not aware she had been seen by either the ambulance service or by Queen Elizabeth the Queen Mother hospital.
(3) The evidence at the inquest revealed that communication between those involved in her short life was inadequate and, as each ran separate clinical records systems, they could not access crucial information which could have made a difference ultimately meaning Hayley may not have died when she did. It is highly likely that the paramedic at South East Coast Ambulance Trust who attended Hayley on 23rd December or the emergency department nurse who saw her at Queen Elizabeth the Queen Mother hospital on 24th December 2019 been aware that Hayley was on a CTO they or her treating mental health team would have been able to take steps which would have saved her life.
(4) Evidence was given at the inquest that locally some steps have been taken to try to share key data between acute hospitals but there have been significant hurdles which have impeded the process namely, the different information technology systems used, licensing issues for the software, Data Protection requirements, confidentiality and consent issues as well as training and funding .
(5) Hayley died following an out of hospital cardiac arrest on Christmas day 2019. If information been shared between different health care organisations particularly crucial information about Hayley’s CTO it is highly likely she would still be alive today.
” Open source report
25 Mar 2022 Natalie Melissa Turner · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 3 Lack of specific guidance for GPs managing eating disorder patients who are not engaging with treatment View source Failure by counsellors to disclose serious eating-disorder risks when breaching confidentiality is justified View source Lack of targeted eating-disorder guidance for counsellors View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Natalie Melissa Turner · 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
Natalie Melissa Turner had a long-standing eating disorder and abused laxatives, causing serious illness and repeated hospital admissions. She died at home on 27 October 2020 from the effects of laxative abuse. The concerns included insufficient guidance for GPs managing eating disorder patients who do not engage with treatment, and insufficient guidance for counsellors on when confidentiality should be breached to protect patients at risk of serious harm.
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 specific guidance for GPs managing eating disorder patients who are not engaging with treatment
Wider context from the report “1. The first issue I raise with Parliamentary Under Secretary of State (Minister for Patient Safety and Primary Care), Department of Health & Social Care.
• The inquest received some helpful evidence from a GP, Dr ████████, of the Ash Tree House Surgery, Kirkham. In court, I acknowledged the response of that surgery to Natalie’s death which I have found to be thorough, open and constructive, and a genuine attempt to minimise the prospect of a recurrence in the future. Dr ████████ explained that notwithstanding her considerable experience as a GP, General Practitioners do not receive specific guidance in relation to eating disorders , which are often very complex in nature.
• It seemed to me that GPs can often find themselves in a difficult position when deciding how to approach dealing with a patient who has an eating disorder, but the situation is all the more challenging when the patient is unwilling to engage with medical professionals and accept treatment which is clearly necessary. Many of these patients ostensibly have capacity to make their own decisions, yet given the nature of their eating disorders may go on to make decisions that are not in their own interests. What the GP can and should do is often unclear.
• The number of patients affected is not insignificant: indeed, the inquest heard that this one local surgery had recently identified thirteen of their patients were facing challenges relating to an eating disorder. GPs can resort to the current mental health legislation, MARSIPAN (Management of Really Sick Patients with Anorexia Nervosa) guidance, and NICE (Eating Disorders Recognition and Treatment) guidance which offers some assistance, but it seems to me that in the absence of guidance which focuses on eating disorder patients and what can be done when a patient is not engaging with treatment, GPs are often left unsure about how to help these patients , and in the absence of some guidance on this issue patients may go without treatment and with potentially fatal consequences.
• In response to Natalie’s death, the Lancashire & South Cumbria NHS Foundation Trust has also responded in a constructive manner and have demonstrated a clear plan to avoid a repetition. This response has included the creation of new posts within the Trust who local GPs will be able to access for guidance and these include a Consultant Dietician and a Consultant Nurse, and hopefully local GPs make use of this new assistance, but this is not always the case elsewhere in the country.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure by counsellors to disclose serious eating-disorder risks when breaching confidentiality is justified
Wider context from the report “2. The second issue I raise with the British Association for Counselling and Psychotherapy (BACP):
• The inquest heard from a BACP Accredited Counsellor, with whom Natalie shared some 63 counselling privately funded counselling sessions between January and October 2020.
• BACP guidance includes a set of core principles which ought to guide counsellors, and the guidance makes clear that in exceptional circumstances the need to safeguard clients from serious harm “may require practitioners to override a commitment to make a client’s wishes and confidentiality the primary concern”. The guidance makes clear that a breach of confidentiality may be justified.
• The Counsellor had developed a good therapeutic relationship with Natalie, but in my judgement she felt unduly constrained by the wishing to avoid breaching Natalie’s confidence , despite she herself having formed the view given what Natalie was disclosing to her about the extent of her ongoing laxative abuse she was at risk of self harm and of dying. These circumstances were exceptional, it is hard to think of a clearer example where to disclose her concerns to others would have been justified but she preferred not to because she did not feel she could betray her confidence . This was despite having regular discussions with her supervisor, and knowing that Natalie was not accessing the medical monitoring that she needed from her GP.
• The Counsellor explained in court that she personally has not knowingly counselled an eating disorder patient before. The potential complexities of these conditions were not fully appreciated.
• Patients with eating disorders will commonly prefer to avoid contact with mainstream medical care and treatment, and their families. It follows that such patients may be attracted to discussing their condition privately with a private counsellor.
• Although the therapeutic relationship between counsellor and patient is fundamentally important, as the BCAP guidance makes clear there are occasions when a breach of confidentiality is justifiable. Counsellors who begin a course of therapy with an eating disorder patient need to appreciate that refraining from breaching confidentiality may well mean the patient goes without necessary and potentially life-saving care and treatment . Even if patients try to reassure counsellors that they are seeking medical help elsewhere, such claims may well not be credible because these patients may be claiming they are being treated as a distraction.
• The Counsellor informed the court she did not have the benefit of guidance on eating disorders. More information may have highlighted the particular risks eating disorder patients may pose, particular as regards whether to breach confidentiality or not. In the absence of such guidance, I am concerned that there is a risk that vulnerable patients – who may in fact benefit from a disclosure by their counsellor – will miss out on necessary and potentially life – saving treatment.
• Whilst acknowledging that on the BACP website [www.bacp.co.uk], within a section headed “Events & resources”, there is a series of articles which explore some of the issues eating disorders may pose for counsellors, the Counsellor who gave evidence at Natalie’s inquest did not appear to be familiar with these articles. This arguably reinforces the need for this subject to be raised with counsellors in a more targeted way.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 targeted eating-disorder guidance for counsellors
Wider context from the report “2. The second issue I raise with the British Association for Counselling and Psychotherapy (BACP):
• The inquest heard from a BACP Accredited Counsellor, with whom Natalie shared some 63 counselling privately funded counselling sessions between January and October 2020.
• BACP guidance includes a set of core principles which ought to guide counsellors, and the guidance makes clear that in exceptional circumstances the need to safeguard clients from serious harm “may require practitioners to override a commitment to make a client’s wishes and confidentiality the primary concern”. The guidance makes clear that a breach of confidentiality may be justified.
• The Counsellor had developed a good therapeutic relationship with Natalie, but in my judgement she felt unduly constrained by the wishing to avoid breaching Natalie’s confidence, despite she herself having formed the view given what Natalie was disclosing to her about the extent of her ongoing laxative abuse she was at risk of self harm and of dying. These circumstances were exceptional, it is hard to think of a clearer example where to disclose her concerns to others would have been justified but she preferred not to because she did not feel she could betray her confidence. This was despite having regular discussions with her supervisor, and knowing that Natalie was not accessing the medical monitoring that she needed from her GP.
• The Counsellor explained in court that she personally has not knowingly counselled an eating disorder patient before. The potential complexities of these conditions were not fully appreciated.
• Patients with eating disorders will commonly prefer to avoid contact with mainstream medical care and treatment, and their families. It follows that such patients may be attracted to discussing their condition privately with a private counsellor.
• Although the therapeutic relationship between counsellor and patient is fundamentally important, as the BCAP guidance makes clear there are occasions when a breach of confidentiality is justifiable. Counsellors who begin a course of therapy with an eating disorder patient need to appreciate that refraining from breaching confidentiality may well mean the patient goes without necessary and potentially life-saving care and treatment. Even if patients try to reassure counsellors that they are seeking medical help elsewhere, such claims may well not be credible because these patients may be claiming they are being treated as a distraction.
• The Counsellor informed the court she did not have the benefit of guidance on eating disorders . More information may have highlighted the particular risks eating disorder patients may pose, particular as regards whether to breach confidentiality or not . In the absence of such guidance, I am concerned that there is a risk that vulnerable patients – who may in fact benefit from a disclosure by their counsellor – will miss out on necessary and potentially life – saving treatment.
• Whilst acknowledging that on the BACP website [www.bacp.co.uk], within a section headed “Events & resources”, there is a series of articles which explore some of the issues eating disorders may pose for counsellors, the Counsellor who gave evidence at Natalie’s inquest did not appear to be familiar with these articles. This arguably reinforces the need for this subject to be raised with counsellors in a more targeted way .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation GPs are responsible for maintaining their clinical knowledge, identifying learning needs and adhering to relevant eating disorder guidance.
Verbatim wording from the response “GPs are responsible for ensuring their own clinical knowledge remains up-to-date and for identifying learning needs as part of their continuing professional development. This activity” Source location Response from Department of Health and Social Care
Open published response
23 Mar 2022 Laura Jane Medcalf · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of mental health inpatient bed capacity causing delays in access to mental health beds View source Adverse impact of Covid-19 lockdown measures on mental health View source Lack of sufficient mental health staffing to keep wards staffed and fully operational View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Laura Jane Medcalf · 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
Laura Jane Medcalf died on 17 February 2021 after being found unresponsive in her mental health ward bed, following a period of repeated self-harm incidents and signs of deteriorating mental health. The investigation concluded that her death was suicide, contributed to by failures to recognise her deteriorating mental health and increased risk, and to take effective steps to reduce that risk. Concerns also included shortages of mental health beds and staffing challenges affecting services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of mental health inpatient bed capacity causing delays in access to mental health beds
Wider context from the report “1. The inquest heard that Laura Medcalf was kept in an acute hospital setting at Salford Royal Hospital awaiting a mental health bed due to a shortage of mental health beds . The inquest heard that there is a national shortage of inpatient beds and that this delay is not unusual .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Adverse impact of Covid-19 lockdown measures on mental health
Wider context from the report “3. The evidence before the inquest was that Covid 19 and the measures to deal with it had a significant impact in a number of respects. In particular that included the impact of lockdown on the mental health of Laura Jane Medcalf.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficient mental health staffing to keep wards staffed and fully operational
Wider context from the report “2. The inquest heard that during the period of time that Laura Medcalf was an in-patient on a mental health ward there were significant staffing challenges . Those challenges were part of a national picture of availability of mental health staff . Against this background and in order to keep the ward staffed and fully operational the trust had to move staff from other mental health services; use agency/bank staff and use leadership and management staff to backfill for nursing staff .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and fund the Mental Health Recovery Action Plan to expand services, reduce waiting times and strengthen the NHS workforce.
Verbatim wording from the response “You also raise the matter of Covid-19 measures, including lockdown. The Covid-19 pandemic required the Government to put a number of unprecedented measures in place, including shielding, social distancing and local and national lockdowns. We know that the pandemic and these measures have had, and will continue to have, an impact on the mental health and wellbeing of many people. That is why we published our Mental Health Recovery Action Plan⁴ in March 2021, backed by an additional £500 million for 2021/22, to accelerate our expansion plans in order to address waiting times for mental health services, give more people the mental health support they need, and invest in the NHS workforce.” 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 community mental-health services to improve support for people with serious mental illnesses and manage bed pressures.
Verbatim wording from the response “An additional £116 million was invested in the NHS in 2021/22 to support people to be discharged safely and appropriately from mental health inpatient units. Improving flow will help ensure beds are available to those most in need. Major expansion in funding for community mental health services commenced in all areas in 2021/22, which has been key to managing pressures on beds. As set out in the NHS Long Term Plan, our aim is to improve community support for serious mental illnesses” 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 Replace mental-health dormitory beds with single, en-suite rooms across more than 50 sites by 2024/25.
Verbatim wording from the response “We are also investing £300 million over this Spending Review to eradicate mental health dormitories by 2024/25. By 2024/25, over 1200 beds in mental health dormitories across more than 50 sites will be replaced with single, en suite rooms. Although this may impact bed availability temporarily, it will support patients by improving their care, safety and sense of dignity.” 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 Commission NHS England to develop a long-term NHS workforce plan addressing staffing requirements, supply gaps and retention.
Verbatim wording from the response “Finally, for the workforce as a whole, we have commissioned NHS England to develop a high-level long-term workforce plan. The plan will look at the mix and number of staff required across all parts of the country for the whole NHS workforce and will set out the actions and reforms that will be needed to reduce supply gaps and improve retention. NHS England are engaging with a broad range of stakeholders in developing this plan and it is due to be completed by the end of 2022.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest in mental-health estate improvements, including non-medical admission alternatives, step-down beds and supported living services.
Verbatim wording from the response “You may also wish to note that the Department is investing £150 million for significant improvements in the mental health estate over the course of the Spending Review (2021). This will be used to support our NHS Long Term Plan ambitions regarding system capacity and pressure reduction. It will cover a range of schemes, including non-medical alternatives to admission, step-down community beds and supported living services.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest in growing the mental-health workforce toward NHS Mental Health Implementation Plan commitments.
Verbatim wording from the response “In addition to the level of growth set out in “Stepping Forward”, the NHS Mental Health Implementation Plan 2019/20–2023/24³ sets out the need for the mental health workforce to grow by over 27,000 during this time frame to support the expansion and transformation of NHS mental health services and give an extra two million people the mental health support they need. The Department invested £111 million in 2021/22 to grow the mental health workforce towards delivering these ambitious commitments. You may also wish to note that Health Education England and NHS England have been working with integrated care systems (ICSs) to confirm plans to 2024. This will aim to ensure a system-wide effort to meet the Mental Health Implementation Plan ambition, looking across service models, supply, retention, and recruitment.” 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 and diversify mental-health workforce roles, meeting the target for 19,000 new staff.
Verbatim wording from the response “The Department is also fully committed to attracting, training, and recruiting the mental health workforce of the future. Through our plans set out in Implementing the Five Year Forward View for Mental Health¹ and Stepping Forward to 2020/2021: The mental health workforce plan for England², the Department have expanded and diversified the types of roles that are 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 Fund safe and appropriate discharge from mental-health inpatient units.
Verbatim wording from the response “An additional £116 million was invested in the NHS in 2021/22 to support people to be discharged safely and appropriately from mental health inpatient units. Improving flow will help ensure beds are available to those most in need. Major expansion in funding for community mental health services commenced in all areas in 2021/22, which has been key to managing pressures on beds. As set out in the NHS Long Term Plan, our aim is to improve community support for serious mental illnesses” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The root cause analysis did not find that a shortage of beds contributed to Ms Medcalf’s death.
Verbatim wording from the response “I understand that several actions have been taken following Ms Medcalf’s death. A Root Cause Analysis was undertaken by Greater Manchester Mental Health NHS FT (GMMH) as a result of Ms Medcalf’s death in line with the patient safety and serious incident process. This did not reveal that a shortage of beds was a contributory factor in this case. However, patient flow continues to be a main priority for the mental health system at a local, regional and national level. You may wish to know that GMMH are addressing these issues through the purchase of independent sector beds, alongside increased investment in schemes and workforce initiatives to support patient flow. In addition, system partners continue to support All-Age Mental Health Liaison teams in A&E and the advisory capacity they offer across Greater Manchester.” Source location Response from Department of Health and Social Care
Open published response
18 Mar 2022 James Forryan · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Easy accessibility of websites and forums openly promoting and advertising suicide methods View source Insufficient regulation or enforcement action against websites promoting criminal offences or harmful content View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Forryan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Forryan died aged 29 after deliberately taking a poisonous quantity of pentobarbital medication at a London hotel. Evidence indicated that he had accessed an internet forum promoting suicide, which provided information about drugs, methods and obtaining medication. The principal concerns were the accessibility of suicide-promoting websites and forums and the apparent lack of sufficient regulation or enforcement action against them.
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 Easy accessibility of websites and forums openly promoting and advertising suicide methods
Wider context from the report “I am concerned that:
(a) There are websites and forums which openly promote and advertise methods of suicide which are easily accessible ;
(b) Suicide is the largest cause of death for individuals in the UK under the age of 35 and James Forryan is within that age bracket;
(c) There does not appear to be sufficient regulation or enforcement action against such websites which promote criminal offences and/or harmful content.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 regulation or enforcement action against websites promoting criminal offences or harmful content
Wider context from the report “I am concerned that:
(a) There are websites and forums which openly promote and advertise methods of suicide which are easily accessible;
(b) Suicide is the largest cause of death for individuals in the UK under the age of 35 and James Forryan is within that age bracket;
(c) There does not appear to be sufficient regulation or enforcement action against such websites which promote criminal offences and/or harmful content .
” 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 Confirm encouraging or assisting suicide as a priority illegal offence under the Online Safety Bill.
Verbatim wording from the response “To address your concern around websites promoting criminal offences and/or harmful content, we are taking urgent steps to protect users, and particularly vulnerable users, online. The Government is committed to tackling this and making the UK the safest place in the world to be online. Under the Online Safety Bill, in-scope companies that allow users to post content online or to interact with each other – including social media platforms and online forums – will need to remove and limit the spread of illegal content and activity online.” 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 online platforms to encourage removal or reduced access to harmful suicide and self-harm material before legislation comes into force.
Verbatim wording from the response “be exposed to extremely harmful and inciting online content. In advance of the legislation coming into force, we are working with online platforms to encourage action to remove or reduce access to harmful suicide and self-harm material.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Online Safety Bill cannot be implemented immediately because legislation takes time to come into force.
Verbatim wording from the response “However, I am also aware that the implementation of legislation takes time, during which individuals, some of whom may be experiencing harmful thoughts, will potentially” Source location Response from Department of Health and Social Care
Open published response
12 Mar 2022 Samuel Alban Stanley · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 9 Exclusion of children with complex neurodevelopmental needs from required care and treatment View source Failure of Children with Disabilities services to assess children with high-risk behaviour View source Inadequate timely communication and follow-up action between agencies View source Inadequate support for families of children with rare diseases and behavioural difficulties View source Failure to offer psychosocial interventions for high-risk behaviour View source Diagnostic-only commissioning for children with autism and learning disabilities without an overt mental health diagnosis View source Lack of knowledge among service staff about available support View source Insufficient funding and replacement support for wrap-around home care View source Failure to implement suggested Care Education and Treatment Reviews View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samuel Alban Stanley · 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
Samuel Alban Stanley died in hospital on 26 April 2020 from injuries sustained during an episode of high-risk behaviour related to his Prader-Willi syndrome. The report raised concerns about inadequate support for him and his family, limited access to appropriate services, and poor communication between agencies.
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 Exclusion of children with complex neurodevelopmental needs from required care and treatment
Wider context from the report “(5) It was clear at the hearing that locally Kent County Council had taken steps to change the way their services were delivered following Sammy’s death but it is predictable that a similar incident may arise in other areas if children with complex neurodevelopmental needs are excluded from accessing the care and treatment they require to 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 Failure of Children with Disabilities services to assess children with high-risk behaviour
Wider context from the report “(2) Evidence was given at the inquest that the social workers from Kent County Council were fully aware of Sammy’s high-risk behaviour and had on several occasions referred him to their Children with Disabilities team who refused to assess him . Sammy’s behaviour was also having an adverse impact on his three younger siblings. His mother had repeatedly reported that she could not keep Sammy safe without support and had sought assistance from state agencies, Charites and done as much as she possibly could herself. Social workers took steps to try to access support for his family to enable them to care for him but the way services were managed meant those involved had little knowledge of what was available. One social worker gave evidence that Sammy’s behaviour had escalated between August 2019 and January 2020 when he did not have access to support in the home. However, despite being aware that Sammy needed more support to provide wrap around care before and after the school day only very limited support was funded from the end of January 2020. When the advice was given for him to shield in March 2020, due to the Covid 19 pandemic, he now had to isolate and was without the supportive school environment yet no replacement support was provided despite the need being obvious.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 timely communication and follow-up action between agencies
Wider context from the report “(4) The evidence at the inquest also revealed that communication between agencies involved in his short life was inadequate . It is possible that had information been shared in a timely manner and actions taken as a result then more support could have been provided to Sammy and his family. Had he, and his family, had more practical help and support this may have made a difference to his high-risk behaviour and ultimately his death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate support for families of children with rare diseases and behavioural difficulties
Wider context from the report “(1) Evidence given at the inquest by Professor ████████ from Great Ormond Street made it clear that the episodes of behavioural difficulties experienced by Sammy were inherently a part of his Prader Willi syndrome. He also indicated that it was not uncommon for the parents of children with behavioural difficulties associated with their underlying disease to inform him that they did not have adequate support . He opined that whilst the risk cannot be eliminated it could be managed through a combination of psychosocial intervention, sometimes with medication and care. He told the court that more support should be available to the families of children with rare diseases such as Prader Willi syndrome .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 offer psychosocial interventions for high-risk behaviour
Wider context from the report “(3) There was evidence given that the mental health team at North East London Foundation Trust were also aware of Sammy’s high-risk behaviours. Support had been provided by a psychology student in the past and he had reportedly responded well to mindfulness therapy and the de-escalation techniques employed by his family. Psychosocial interventions were not offered by the Mental Health Trust and a Care Education and Treatment Review was suggested but not implemented before Sammy’s death. The court heard that such interventions may not have been successful but, in any event, North East London Foundation Trust had not been commissioned to provide anything other than a diagnostic service to children presenting with autism and learning disabilities rather than an overt mental health diagnosis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Diagnostic-only commissioning for children with autism and learning disabilities without an overt mental health diagnosis
Wider context from the report “(3) There was evidence given that the mental health team at North East London Foundation Trust were also aware of Sammy’s high-risk behaviours. Support had been provided by a psychology student in the past and he had reportedly responded well to mindfulness therapy and the de-escalation techniques employed by his family. Psychosocial interventions were not offered by the Mental Health Trust and a Care Education and Treatment Review was suggested but not implemented before Sammy’s death. The court heard that such interventions may not have been successful but, in any event, North East London Foundation Trust had not been commissioned to provide anything other than a diagnostic service to children presenting with autism and learning disabilities rather than an overt mental health diagnosis .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge among service staff about available support
Wider context from the report “(2) Evidence was given at the inquest that the social workers from Kent County Council were fully aware of Sammy’s high-risk behaviour and had on several occasions referred him to their Children with Disabilities team who refused to assess him. Sammy’s behaviour was also having an adverse impact on his three younger siblings. His mother had repeatedly reported that she could not keep Sammy safe without support and had sought assistance from state agencies, Charites and done as much as she possibly could herself. Social workers took steps to try to access support for his family to enable them to care for him but the way services were managed meant those involved had little knowledge of what was available . One social worker gave evidence that Sammy’s behaviour had escalated between August 2019 and January 2020 when he did not have access to support in the home. However, despite being aware that Sammy needed more support to provide wrap around care before and after the school day only very limited support was funded from the end of January 2020. When the advice was given for him to shield in March 2020, due to the Covid 19 pandemic, he now had to isolate and was without the supportive school environment yet no replacement support was provided despite the need being obvious.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 funding and replacement support for wrap-around home care
Wider context from the report “(2) Evidence was given at the inquest that the social workers from Kent County Council were fully aware of Sammy’s high-risk behaviour and had on several occasions referred him to their Children with Disabilities team who refused to assess him. Sammy’s behaviour was also having an adverse impact on his three younger siblings. His mother had repeatedly reported that she could not keep Sammy safe without support and had sought assistance from state agencies, Charites and done as much as she possibly could herself. Social workers took steps to try to access support for his family to enable them to care for him but the way services were managed meant those involved had little knowledge of what was available. One social worker gave evidence that Sammy’s behaviour had escalated between August 2019 and January 2020 when he did not have access to support in the home. However, despite being aware that Sammy needed more support to provide wrap around care before and after the school day only very limited support was funded from the end of January 2020 . When the advice was given for him to shield in March 2020, due to the Covid 19 pandemic, he now had to isolate and was without the supportive school environment yet no replacement support was provided despite the need being obvious .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 implement suggested Care Education and Treatment Reviews
Wider context from the report “(3) There was evidence given that the mental health team at North East London Foundation Trust were also aware of Sammy’s high-risk behaviours. Support had been provided by a psychology student in the past and he had reportedly responded well to mindfulness therapy and the de-escalation techniques employed by his family. Psychosocial interventions were not offered by the Mental Health Trust and a Care Education and Treatment Review was suggested but not implemented before Sammy’s death . The court heard that such interventions may not have been successful but, in any event, North East London Foundation Trust had not been commissioned to provide anything other than a diagnostic service to children presenting with autism and learning disabilities rather than an overt mental health diagnosis.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department cannot comment on matters relating to school support or children’s social care.
Verbatim wording from the response “Finally, I would add that this Department is not able to comment on issues relating to school support or children’s social care. You may, therefore, also wish to raise your concerns directly with the Department for Education, at the below address:” 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 Concerns about school support or children’s social care should be raised directly with the Department for Education.
Verbatim wording from the response “Finally, I would add that this Department is not able to comment on issues relating to school support or children’s social care. You may, therefore, also wish to raise your concerns directly with the Department for Education, at the below address:” 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 Commissioners are responsible for ensuring locally appropriate health and social care services, including services for people with complex needs.
Verbatim wording from the response “You may wish to know that under the Equality Act (2010), health and social care organisations must make reasonable adjustments to ensure that disabled people are not disadvantaged. Commissioners are responsible for ensuring the provision of services based on the local needs of their population, including for people with learning disabilities, mental health problems and complex physical needs. Commissioners should take into consideration any relevant guidance, such as those published by the National Institute for Health and Care Excellence in designing their local services.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 11 Continuing gaps in gambling-related information View source Lack of medical professional training in diagnosing and treating gambling addiction View source Failure of gambling regulation to stop gambling by people with obvious gambling addiction View source Lack of understanding that gambling addiction is not the individual's fault View source Continuing gaps in gambling warnings View source Lack of gambling education for school children View source Insufficient gambling warnings to prevent gambling View source Insufficient information to prevent gambling or inform people about available help and treatment View source Insufficient GP training and knowledge to deal effectively with gambling problems View source Continuing gaps in gambling addiction treatment View source Insufficient treatment for gambling addiction View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
JACK WILLIAM RAMSEY RITCHIE · 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
Jack William Ramsey Ritchie died on 22 November 2017 from multiple injuries after an incident in Hanoi, Vietnam, in which the evidence indicated he intended to take his own life. The report raised concerns about gambling regulation, warnings, information, treatment, professional training, the stigma associated with gambling addiction, and limited education for young people about gambling harms.
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 Continuing gaps in gambling-related information
Wider context from the report “- That in the time since Jack’s death, whilst there have been improvements made in the areas of warnings, information, training and treatment , the evidence showed there were still significant gaps in these areas . One notable gap was the fact that evidence suggested GPs currently have insufficient training and knowledge to deal effectively with gambling problems. This was of particular concern given many gamblers affected are likely to contact a GP as their first attempt to seek help
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 medical professional training in diagnosing and treating gambling addiction
Wider context from the report “- The treatment available to and received by Jack was insufficient to cure his addiction – this in part was due to a lack of training for medical professionals around the diagnosis and treatment of gambling addiction
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 gambling regulation to stop gambling by people with obvious gambling addiction
Wider context from the report “- That the system of regulation in force at the time of his death did not stop Jack gambling at a point when he was obviously addicted to gambling
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding that gambling addiction is not the individual's fault
Wider context from the report “- Jack didn’t understand that being addicted to gambling wasn’t his fault . That lack of understanding lead to feelings of shame and hopelessness which in turn, contributed to him feeling suicidal
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 gaps in gambling warnings
Wider context from the report “- That in the time since Jack’s death, whilst there have been improvements made in the areas of warnings , information, training and treatment, the evidence showed there were still significant gaps in these areas . One notable gap was the fact that evidence suggested GPs currently have insufficient training and knowledge to deal effectively with gambling problems. This was of particular concern given many gamblers affected are likely to contact a GP as their first attempt to seek help
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 gambling education for school children
Wider context from the report “- The evidence was that young people were the most at risk from the harms of gambling yet there was and still appears to be, very little education for school children on the subject .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 gambling warnings to prevent gambling
Wider context from the report “- The warnings Jack received were insufficient to prevent him gambling
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 information to prevent gambling or inform people about available help and treatment
Wider context from the report “- The information available to Jack was insufficient to prevent him gambling or to inform him of the help / treatments available
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 GP training and knowledge to deal effectively with gambling problems
Wider context from the report “- That in the time since Jack’s death, whilst there have been improvements made in the areas of warnings, information, training and treatment, the evidence showed there were still significant gaps in these areas. One notable gap was the fact that evidence suggested GPs currently have insufficient training and knowledge to deal effectively with gambling problems . This was of particular concern given many gamblers affected are likely to contact a GP as their first attempt to seek help
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 gaps in gambling addiction treatment
Wider context from the report “- That in the time since Jack’s death, whilst there have been improvements made in the areas of warnings, information, training and treatment , the evidence showed there were still significant gaps in these areas . One notable gap was the fact that evidence suggested GPs currently have insufficient training and knowledge to deal effectively with gambling problems. This was of particular concern given many gamblers affected are likely to contact a GP as their first attempt to seek help
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 treatment for gambling addiction
Wider context from the report “- The treatment available to and received by Jack was insufficient to cure his addiction – this in part was due to a lack of training for medical professionals around the diagnosis and treatment of gambling addiction
” Open source report
22 Feb 2022 VAN THAI TUYEN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Lack of a unified approach to address ongoing use of misplaced nasogastric tubes View source Continuing use of misplaced nasogastric tubes to administer liquids or medications 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
VAN THAI TUYEN · 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
Van Thai Tuyen was admitted to hospital for stroke treatment and, after a nasogastric tube was misplaced into his right lung, approximately 300ml of liquid feed was administered through it. He died from cavitating necrotising pneumonia. The principal concerns were the use of misplaced nasogastric tubes, the recurrence of such incidents, and the absence of a unified approach to preventing avoidable deaths from this problem.
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 unified approach to address ongoing use of misplaced nasogastric tubes
Wider context from the report “(1) Using a misplaced nasogastric tube is recognised as a ‘never event’, namely an event which is wholly preventable and should never happen.
(2) The court heard evidence at the inquest that an NHS improvement patient safety alert issued in 2016 identified that between 2011-2016 there had been 95 incidents of misplaced nasogastric tubes used to administer fluids or medication, 32 of which resulted in death.
(3) The court heard that there had been Barts NHS Trust had had at least 7 incidents relating to misplaced nasogastric tube since 2012.
(4) The court heard that the use of misplaced nasogastric tubes to administer liquids or medications continues to take place in Trusts across the country
(5) The court heard that there is no unified approach to address the on going issue of avoidable deaths caused by using misplaced nasogastric tubes .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 use of misplaced nasogastric tubes to administer liquids or medications
Wider context from the report “(1) Using a misplaced nasogastric tube is recognised as a ‘never event’, namely an event which is wholly preventable and should never happen.
(2) The court heard evidence at the inquest that an NHS improvement patient safety alert issued in 2016 identified that between 2011-2016 there had been 95 incidents of misplaced nasogastric tubes used to administer fluids or medication, 32 of which resulted in death.
(3) The court heard that there had been Barts NHS Trust had had at least 7 incidents relating to misplaced nasogastric tube since 2012.
(4) The court heard that the use of misplaced nasogastric tubes to administer liquids or medications continues to take place in Trusts across the country
(5) The court heard that there is no unified approach to address the on going issue of avoidable deaths caused by using misplaced nasogastric tubes.
” Open source report
17 Feb 2022 Chloe May Lumb · Prevention of Future Deaths report Teesside and Hartlepool
View report summary
Concerns raised 2 Lack of clinical guidance or pathway for suspected aortic dissection requiring ECG-gated CT scanning View source Failure to alert Emergency Department staff to patients’ genetic risk of aortic dissection 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
Chloe May Lumb · 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
Chloe May Lumb, who was known to have a genetic risk of aortic dissection, died in Redcar on 8 January 2021. She presented to hospital on 4 January with clinical symptoms and imaging findings, but the dissection was not diagnosed, and when she contacted the hospital on 5 January because of ongoing symptoms, she was advised to contact her GP rather than return to hospital. The principal concerns were the absence of an Emergency Department pathway requiring an ECG-gated CT scan for suspected aortic dissection and the lack of a mechanism alerting staff to her genetic risk.
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 clinical guidance or pathway for suspected aortic dissection requiring ECG-gated CT scanning
Wider context from the report “There was no clinical guidance or pathway within the Emergency Department of the hospital for patients presenting with suspected aortic dissection that should have included a directive to ensure that an ECG gated CT scan is carried out to exclude the possibility of such condition.
When the Emergency Department were contacted by Ms Lumb on 5th January 2021 there was no mechanism by which staff were alerted to her genetic risk of aortic dissection leading to advice merely to contact her GP
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to alert Emergency Department staff to patients’ genetic risk of aortic dissection
Wider context from the report “There was no clinical guidance or pathway within the Emergency Department of the hospital for patients presenting with suspected aortic dissection that should have included a directive to ensure that an ECG gated CT scan is carried out to exclude the possibility of such condition.
When the Emergency Department were contacted by Ms Lumb on 5th January 2021 there was no mechanism by which staff were alerted to her genetic risk of aortic dissection leading to advice merely to contact her GP
” Open source report
15 Feb 2022 Mr Jason Lennon · Prevention of Future Deaths report East London
View report summary
Concerns raised 8 Failure to effectively review medical records before assessment View source CRT staff performance falling below regulator standards View source Failure to adequately document important information arising from assessment View source Failure to monitor whether patients are on care pathways appropriate to their needs View source Failure of governance processes to complete serious incident investigation action plans View source Failure to evidence consideration of necessary referrals to a regulator View source Failure to communicate important clinical information between CRT staff and external stakeholders View source Failure to assess mental state, relapse and risk of harm View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Jason Lennon · 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
Jason Lennon, a 37-year-old man living in supported accommodation, died on 31 July 2019 after being found unresponsive while restrained in a prone position by security officers at the Excel Centre; resuscitation efforts later ceased in hospital. The concerns included failures in community mental health care, including inadequate monitoring, assessment, communication and documentation, and the extent and manner of the restraint used by security officers. The report also identified deficiencies in the Trust’s serious incident action plan and uncertainty about whether regulatory referral had been considered.
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 effectively review medical records before assessment
Wider context from the report “2. The CRT undertook a flawed review of Mr Lennon’s mental state on 29/7/19 which failed to assess that, Jason was in relapse and was a risk of harm to himself and others.
Factors which contributed to this failure included;
a. CRT staff did not effectively review medical records prior to assessing Jason,
b. The CRT did not communicate important clinical information between themselves and external stakeholders.
c. The CRT did not adequately document important information arising from the assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation CRT staff performance falling below regulator standards
Wider context from the report “4. Accepted individual failings by staff within the CRT fall below standards set by their regulator. There is no evidence before the court to assess whether ELFT have considered the necessity to make a referral to a regulator.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately document important information arising from assessment
Wider context from the report “2. The CRT undertook a flawed review of Mr Lennon’s mental state on 29/7/19 which failed to assess that, Jason was in relapse and was a risk of harm to himself and others.
Factors which contributed to this failure included;
a. CRT staff did not effectively review medical records prior to assessing Jason,
b. The CRT did not communicate important clinical information between themselves and external stakeholders.
c. The CRT did not adequately document important information arising from the assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor whether patients are on care pathways appropriate to their needs
Wider context from the report “1. Expert psychiatric evidence indicated that Mr Lennon was a suitable candidate for the Care Programme Approach mental health pathway and that the use of this pathway would have reduced the risk of an acute deterioration in his mental state. The CRT failed to effectively monitor whether Mr Lennon was on a care pathway appropriate to his needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 governance processes to complete serious incident investigation action plans
Wider context from the report “3. The Trust undertook a serious incident investigation report into the events leading to Mr Lennon’s death in November 2019 which made a series of recommendations for action. The action plan was found to have been incomplete by 6/2/22 due to errors attributable to the Trust’s governance team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to evidence consideration of necessary referrals to a regulator
Wider context from the report “4. Accepted individual failings by staff within the CRT fall below standards set by their regulator. There is no evidence before the court to assess whether ELFT have considered the necessity to make a referral to a regulator.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 communicate important clinical information between CRT staff and external stakeholders
Wider context from the report “2. The CRT undertook a flawed review of Mr Lennon’s mental state on 29/7/19 which failed to assess that, Jason was in relapse and was a risk of harm to himself and others.
Factors which contributed to this failure included;
a. CRT staff did not effectively review medical records prior to assessing Jason,
b. The CRT did not communicate important clinical information between themselves and external stakeholders.
c. The CRT did not adequately document important information arising from the assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to assess mental state, relapse and risk of harm
Wider context from the report “2. The CRT undertook a flawed review of Mr Lennon’s mental state on 29/7/19 which failed to assess that, Jason was in relapse and was a risk of harm to himself and others.
Factors which contributed to this failure included;
a. CRT staff did not effectively review medical records prior to assessing Jason,
b. The CRT did not communicate important clinical information between themselves and external stakeholders.
c. The CRT did not adequately document important information arising from the assessment.
” Open source report
11 Feb 2022 Matthew McManus · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Lack of coordinated support and care with a single point of contact View source Failure to identify and assess complex mental health and social care needs View source Failure of agencies to share information and undertake joint assessment and planning View source Failure to assess and manage risk to self through a care plan View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Matthew McManus · 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
Matthew McManus, who had complex mental health and social care needs, died at the scene after sustaining multiple injuries on 9 November 2020. The report concluded suicide and identified a lack of coordinated care, information sharing, joint assessment and risk planning across the agencies supporting him. It raised concern that without a clear pathway for jointly assessing and coordinating care for adults with complex mental health and social care needs, future deaths may occur.
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 coordinated support and care with a single point of contact
Wider context from the report “Matthew McManus had complex mental health and social care needs. He was in contact with a significant number of agencies many of which focused on the risk that Matthew posed to others. However, the evidence before me, particularly that of the Salford Safeguarding Board indicates that no -one saw Matthew as the vulnerable adult he was and addressed how his own complex needs were to be met, either through a Care Act assessment or any other means.
████████, on behalf of the Safeguarding Board who conducted a Safeguarding Adult Review told the Inquest that there was no one person or agency co-ordinating his support and care , meaning that Matthew did not have a single point of contact to help him understand and navigate the services being offered to him . This became particularly concerning when Matthew’s mental health declined, making him more erratic and difficult to contact. This left already stretched services to do what they could to pull information together from their own resources or conversations with other agencies. Without proper co-ordination, there was no full information sharing, joint assessment, or joint planning of Matthew’s support, which meant there was never a full appreciation of the risk he posed to himself, and no real care plan was in place to manage that risk.
Without a clear pathway for agencies to jointly assess and co-ordinate care in the case of adults with complex mental health and social care needs, I am concerned that future deaths will occur.
A copy of the SSAB Safeguarding Adult Review can be found at this link
https://safeguardingadults.salford.gov.uk/media/1291/version-for-publication-ssab-discretionary-sar-matthew.pdf
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and assess complex mental health and social care needs
Wider context from the report “Matthew McManus had complex mental health and social care needs. He was in contact with a significant number of agencies many of which focused on the risk that Matthew posed to others. However, the evidence before me, particularly that of the Salford Safeguarding Board indicates that no -one saw Matthew as the vulnerable adult he was and addressed how his own complex needs were to be met, either through a Care Act assessment or any other means .
████████, on behalf of the Safeguarding Board who conducted a Safeguarding Adult Review told the Inquest that there was no one person or agency co-ordinating his support and care, meaning that Matthew did not have a single point of contact to help him understand and navigate the services being offered to him. This became particularly concerning when Matthew’s mental health declined, making him more erratic and difficult to contact. This left already stretched services to do what they could to pull information together from their own resources or conversations with other agencies. Without proper co-ordination, there was no full information sharing, joint assessment, or joint planning of Matthew’s support, which meant there was never a full appreciation of the risk he posed to himself, and no real care plan was in place to manage that risk.
Without a clear pathway for agencies to jointly assess and co-ordinate care in the case of adults with complex mental health and social care needs, I am concerned that future deaths will occur.
A copy of the SSAB Safeguarding Adult Review can be found at this link
https://safeguardingadults.salford.gov.uk/media/1291/version-for-publication-ssab-discretionary-sar-matthew.pdf
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 agencies to share information and undertake joint assessment and planning
Wider context from the report “Matthew McManus had complex mental health and social care needs. He was in contact with a significant number of agencies many of which focused on the risk that Matthew posed to others. However, the evidence before me, particularly that of the Salford Safeguarding Board indicates that no -one saw Matthew as the vulnerable adult he was and addressed how his own complex needs were to be met, either through a Care Act assessment or any other means.
████████, on behalf of the Safeguarding Board who conducted a Safeguarding Adult Review told the Inquest that there was no one person or agency co-ordinating his support and care, meaning that Matthew did not have a single point of contact to help him understand and navigate the services being offered to him. This became particularly concerning when Matthew’s mental health declined, making him more erratic and difficult to contact. This left already stretched services to do what they could to pull information together from their own resources or conversations with other agencies. Without proper co-ordination, there was no full information sharing, joint assessment, or joint planning of Matthew’s support , which meant there was never a full appreciation of the risk he posed to himself, and no real care plan was in place to manage that risk.
Without a clear pathway for agencies to jointly assess and co-ordinate care in the case of adults with complex mental health and social care needs, I am concerned that future deaths will occur.
A copy of the SSAB Safeguarding Adult Review can be found at this link
https://safeguardingadults.salford.gov.uk/media/1291/version-for-publication-ssab-discretionary-sar-matthew.pdf
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and manage risk to self through a care plan
Wider context from the report “Matthew McManus had complex mental health and social care needs. He was in contact with a significant number of agencies many of which focused on the risk that Matthew posed to others. However, the evidence before me, particularly that of the Salford Safeguarding Board indicates that no -one saw Matthew as the vulnerable adult he was and addressed how his own complex needs were to be met, either through a Care Act assessment or any other means.
████████, on behalf of the Safeguarding Board who conducted a Safeguarding Adult Review told the Inquest that there was no one person or agency co-ordinating his support and care, meaning that Matthew did not have a single point of contact to help him understand and navigate the services being offered to him. This became particularly concerning when Matthew’s mental health declined, making him more erratic and difficult to contact. This left already stretched services to do what they could to pull information together from their own resources or conversations with other agencies. Without proper co-ordination, there was no full information sharing, joint assessment, or joint planning of Matthew’s support, which meant there was never a full appreciation of the risk he posed to himself , and no real care plan was in place to manage that risk .
Without a clear pathway for agencies to jointly assess and co-ordinate care in the case of adults with complex mental health and social care needs, I am concerned that future deaths will occur.
A copy of the SSAB Safeguarding Adult Review can be found at this link
https://safeguardingadults.salford.gov.uk/media/1291/version-for-publication-ssab-discretionary-sar-matthew.pdf
” 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 Implement the Community Mental Health Framework with named keyworkers, multidisciplinary teams and joined-up personalised care planning.
Verbatim wording from the response “I would like to assure you that we are, through the development and implementation in local areas of the Community Mental Health Framework (CMHF), working to improve the way people with mental health conditions access joined-up support across health and social care, as well other parts of local systems. I would also like to assure you that more broadly we are bringing a broad range of local services closer together through the Health and Care Act 2022 and the integrated care systems (ICSs) that were formed as a result.” Source location Response from Department of Health and Social Care
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations