Concerns raised 8 Failure to protect questionnaire answers from alteration View source Failure to flag refusal to share prescribing information for further enquiry View source Lack of central tracking of prescribed and dispensed drugs View source Lack of required face-to-face consultation before dispensing drugs View source Inadequate questionnaire on the person's medical history View source Failure to notify the person's GP of prescribed drugs View source Limited regulation of the prescribing company View source Failure to prevent drug selection before prescriber contact View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jamie Francis O'Connor · 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
Jamie O’Connor was found deceased in the garden of his home in Leicester on 14 October 2018 after his mother became concerned that he was not responding to phone calls. The report identified concerns about online prescribing, including the lack of central tracking, limited information sharing with GPs, no required face-to-face consultation, limited questionnaires, patients requesting specific drugs, and limited regulation; the inquest concluded that this was a drug-related death and recorded the cause as ████████ toxicity.
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 protect questionnaire answers from alteration
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed ;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 flag refusal to share prescribing information for further enquiry
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 central tracking of prescribed and dispensed drugs
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of required face-to-face consultation before dispensing drugs
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed ;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 questionnaire on the person's medical history
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the person's GP of prescribed drugs
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Limited regulation of the prescribing company
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent drug selection before prescriber contact
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber ;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with healthcare regulators on digital healthcare provision.
Verbatim wording from the response “The Department is working with other healthcare regulators including the General Medical Council and their equivalents in Scotland, Wales and Northern Ireland in the area of digital healthcare provision. As a result, a review of the UK’s legislative position was undertaken and gaps identified. These included cases involving inappropriate prescribing and a lack of checks with the patient’s GP before prescribing. There were also concerns about the absence of pharmacy records of medicines dispensed by other pharmacies. The Department and healthcare regulators are also working together to review prescribing by private prescribers in relation to controlled drugs.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the UK legislative position on digital healthcare and identify regulatory gaps.
Verbatim wording from the response “The Department is working with other healthcare regulators including the General Medical Council and their equivalents in Scotland, Wales and Northern Ireland in the area of digital healthcare provision. As a result, a review of the UK’s legislative position was undertaken and gaps identified. These included cases involving inappropriate prescribing and a lack of checks with the patient’s GP before prescribing. There were also concerns about the absence of pharmacy records of medicines dispensed by other pharmacies. The Department and healthcare regulators are also working together to review prescribing by private prescribers in relation to controlled drugs.” Source location Response from DHSC
Open published response
14 Oct 2021 Louie Neil Johnston · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Failure to ensure medical staff complete mandated annual CTG training View source Failure of CTG monitoring equipment to keep the CTG trace clearly visible during delivery 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
Louie Neil Johnston · 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
Louie Neil Johnston died in hospital on 28 April 2020 from diffuse hypoxic ischaemic encephalopathy caused by inadequate oxygen supply to his brain during delivery. The report identified avoidable delivery delays, limitations in CTG monitoring equipment, and gaps in mandatory CTG training for staff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure medical staff complete mandated annual CTG training
Wider context from the report “2. A review of staff training records indicated that an obstetric registrar involved in the delivery was not up to date with mandated annual CTG training . Additionally, the obstetric consultant had not completed annual training which required the session to be repeated following the death of Louie Johnston. Systems in place at the Trust did not ensure that all medical staff had completed requisite training .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 CTG monitoring equipment to keep the CTG trace clearly visible during delivery
Wider context from the report “1. CTG trace monitoring equipment that was in use in the labour ward required staff to switch from a CTG trace screen to a K2 electronic recording screen during delivery . This meant that a graphic representation of the CTG trace was not clearly visible at all times . Instead, midwifery staff were required to crouch down and record numeric data from the CTG displayed on a small LED screen. The Trust identified this as counter-productive and raised the issue with the manufacturer of the system. To date, the system has not been updated .
” Open source report
12 Oct 2021 Mrs Vivien Brunning · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Omissions of prescribed daily low molecular weight heparin injections View source Failure to report noticed medication omissions through the incident reporting system View source Failure to undertake required venous thromboembolism reviews at 24 and 72 hours following admission View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mrs Vivien Brunning · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Vivien Brunning was admitted to hospital with sepsis and treated for a kidney stone, during which prescribed Clexane was temporarily held and then omitted on 13 and 14 July 2020. She developed a right brachial artery thrombosis, suffered a stroke during emergency thrombolysis, and died on 25 July 2020. Concerns included missed venous thromboembolism reviews, omitted anticoagulant doses, and failure to report the initial omission through the Trust’s incident reporting system.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Omissions of prescribed daily low molecular weight heparin injections
Wider context from the report “2. Prescribed daily injections of low molecular weight heparin were omitted on 13th and 14th July 2020
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 report noticed medication omissions through the incident reporting system
Wider context from the report “3. The initial omission on 13th July 2020 was noticed by a ward doctor but was not reported through the Trust’s incident reporting system .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake required venous thromboembolism reviews at 24 and 72 hours following admission
Wider context from the report “1. The hospital notes demonstrate that required venous thromboembolism reviews at 24 & 72 hrs following admission were not undertaken .
” Open source report
12 Oct 2021 Mrs Helena Opoku · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to assess the suitability of vulnerable residents' homes View source Delays in appointing social workers to vulnerable persons View source Failure to properly investigate safeguarding referrals 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
Mrs Helena Opoku · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Helena Opoku was pronounced deceased at home on 4 April 2021 after dying from carbon monoxide toxicity associated with using charcoal braziers for cooking and heating after her gas and electricity had been disconnected. The report raised concerns about social services’ failure to investigate safeguarding referrals, appoint social workers within a reasonable timeframe, and assess vulnerable residents’ homes during January to March 2021.
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 assess the suitability of vulnerable residents' homes
Wider context from the report “2. During the same period the team was unable to appoint social workers to vulnerable persons within a reasonable timeframe or carry out assessments of the suitability of the homes of vulnerable residents .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 appointing social workers to vulnerable persons
Wider context from the report “2. During the same period the team was unable to appoint social workers to vulnerable persons within a reasonable timeframe or carry out assessments of the suitability of the homes of vulnerable residents.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 properly investigate safeguarding referrals
Wider context from the report “1. During January- March 2021 the London Borough of Redbridge social services adult social care team in Cranbrook and Loxford were unable to; properly investigate all but the most acute safeguarding referrals made to them ;
” Open source report
1 Oct 2021 Stephen Thomas BARTON · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 1 Lack of tracking systems for non-cancer outpatient appointments 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
Stephen Thomas BARTON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Thomas BARTON, a serving prisoner, was found dead in his cell at HMP Dovegate on 27 July 2019; the circumstances state that death resulted from an ear condition. He missed numerous outpatient appointments, and concerns were raised about the lack of systems to track such appointments and about insufficient access to secondary healthcare, alongside a conclusion of natural causes following a lack of proper primary healthcare intervention.
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 tracking systems for non-cancer outpatient appointments
Wider context from the report “Stephen missed numerous out-patient appointments. I heard expert evidence from a hospital consultant indicating that in the great majority of cases there is no way of tracking out-patient appointments in the NHS . This is however done in cancer cases . The consultant felt it should not be too difficult to develop a system of tracking out-patient appointments in non-cancerous cases. If realistically this could be introduced it might well save a lot of administrative time and indeed prevent unnecessary deaths.
” Open source report
30 Sep 2021 Stephen David COPE · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Premature closure of ACCTs for newly transferred prisoners before sufficient review, assessment and communication View source ACCT closure criteria being vulnerable to manipulation through two negative prisoner responses View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen David COPE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen David Cope died by suspension in his own cell block at Belmarsh prison on 18 November 2019. The principal concern was the transfer and review of prisoners on an ACCT, particularly the closure of an ACCT shortly after a prisoner’s transfer before support services had sufficient time to assess and communicate about 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 Premature closure of ACCTs for newly transferred prisoners before sufficient review, assessment and communication
Wider context from the report “(1) The transfer and review of prisoners on an ACCT.
I am concerned in relation to the ability of any Prison to close an ACCT, with the attendance of 2 individuals (a prison and health care staff), after a short period of time on a newly transferred inmate (i.e. to a new prison) before anyone has had the time to review and assess him or her .
For ACCTs created on current inmates within an establishment, who are known to staff, I do not see that as an issue, they would already have an existing knowledge and relationship and indeed would have been the originator of the ACCT in any event.
However, for new prisoners, who have arrived from another prison establishment with an open ACCT on their record, I consider the ability to remove that individual from the ACCT, within a short period of time, does raise issues in respect of the knowledge and understanding of that individual and the ability of various agencies, within the prison, to have had time to review and communicate between themselves, about that individual .
The provision of in effect 2 ‘no’ answers by a prisoner, is a potentially easy way of coming off an ACCT, which is there for their support and well-being, and I would suggest, given to easy manipulation
I raise the issue as to whether there should be, for example, a set review period (e.g. 7 days) which allows time for the support services to meet with and interview the transferred inmate, interact, and then make a decision about and with the newly transferred prisoner on the ACCT before such an ACCT is closed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation ACCT closure criteria being vulnerable to manipulation through two negative prisoner responses
Wider context from the report “(1) The transfer and review of prisoners on an ACCT.
I am concerned in relation to the ability of any Prison to close an ACCT, with the attendance of 2 individuals (a prison and health care staff), after a short period of time on a newly transferred inmate (i.e. to a new prison) before anyone has had the time to review and assess him or her.
For ACCTs created on current inmates within an establishment, who are known to staff, I do not see that as an issue, they would already have an existing knowledge and relationship and indeed would have been the originator of the ACCT in any event.
However, for new prisoners, who have arrived from another prison establishment with an open ACCT on their record, I consider the ability to remove that individual from the ACCT, within a short period of time, does raise issues in respect of the knowledge and understanding of that individual and the ability of various agencies, within the prison, to have had time to review and communicate between themselves, about that individual.
The provision of in effect 2 ‘no’ answers by a prisoner, is a potentially easy way of coming off an ACCT , which is there for their support and well-being, and I would suggest, given to easy manipulation
I raise the issue as to whether there should be, for example, a set review period (e.g. 7 days) which allows time for the support services to meet with and interview the transferred inmate, interact, and then make a decision about and with the newly transferred prisoner on the ACCT before such an ACCT is closed.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for the ACCT process lies with HMPPS, which has responded on this matter.
Verbatim wording from the response “Responsibility for the Assessment, Care in Custody and Teamwork (ACCT) process lies with HMPPS and I am aware that it has responded to you on this matter. A new version of the ACCT has been introduced with changes that include an increased emphasis on information sharing, strengthened case reviews and post-closure procedures. In particular, I note that updated guidance accompanying the ACCT makes clear that when a change of circumstance takes place, such as transfer to another prison, an urgent case review must take place, prior to transfer, and as soon as possible at the receiving prison, informed by handover.” Source location 2021-0332-Response-from-Department-of-Health-Social-Care_Published
Open published response
29 Sep 2021 Mary Land · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1 Use of a mask-to-tubing push-on connection vulnerable to coming apart View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mary Land · 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
Mary Land, aged 76, was being treated for COVID pneumonia when she was found unresponsive with the tubing connecting her facemask to a BIPAP ventilator detached. The Inquest could not determine whether the detachment contributed to her death, but identified concern that the push-on connection could come undone and may require a more robust docking mechanism.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Use of a mask-to-tubing push-on connection vulnerable to coming apart
Wider context from the report “The Philips Respironics AF 541 mask connects to the tubing, linking it to the BIPAP ventilator by means of a ‘push on’ connection (rather than a fitting involving positive engagement) . Evidence taken at the Inquest indicates this connection has come undone on other occasions as well . The introduction of a filter at the site of this union increases the potential for the joint to come apart . Consideration should be given to installing a more robust docking mechanism which is less vulnerable to working loose, or being inadvertently pulled apart , for example, by a patient suffering from delirium.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The MHRA is responsible for ensuring the device investigation complies with regulations and that any identified corrective action is taken.
Verbatim wording from the response “I have been made aware that the Medicine and Healthcare products Regulatory Agency (MHRA), the regulator of medical devices and medicinal products, has provided a response to your report explaining the actions it has taken in relation to this incident and the concerns raised. You will therefore be aware that following the outcome of the inquest into Mrs Land’s death, Phillips Respironics has extended its investigation to look at the connection tubing and facemask. Phillips has also been asked by the MHRA to investigate the potential impact on performance of the breathing circuit of using a filter in the facemask. A final report of the investigation has been requested by the MHRA, and the MHRA will ensure that the investigation has been conducted in line with the relevant regulations and that any corrective action identified is taken.” Source location 2021-0322-Response-from-Department-of-Health-and-Social-Care_Published-1
Open published response
Concerns raised 4 Inability of some households to purchase balanced, good-quality nutrition for children View source Failure of other professionals, friends and family to report concerns about children’s health View source Insufficient one-to-one consultations for health professionals to identify signs of anaemia in children View source Increased incidence of severe nutritional anaemia and associated deaths in children 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
Maya ZAB · 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
Maya Zab died from multi-organ failure associated with chronic severe microcytic hypochromic anaemia and severe iron deficiency on 6 August 2020. The report raised concerns about increased severe nutritional anaemia and deaths among children in the Yorkshire & Humber region during 2020, with possible indirect effects of the pandemic including fewer consultations, reduced social contact, and widening socioeconomic inequalities.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inability of some households to purchase balanced, good-quality nutrition for children
Wider context from the report “During the evidence it became clear that in the Yorkshire & Humber region there has been an increased incidence of severe nutritional anaemia in 2020 in a paediatric setting, resulting in 2 deaths, Maya’s death being one of the two. The witness had not seen any deaths previously in her career.
The witness had consulted 9 colleagues over the data. They surmise that a number of factors arising indirectly from the pandemic may explain the findings:
• The “stay at home” message resulted in less 1 to 1 consultations, so health professionals were not able to spot the signs of anaemia
• Limitation of social contact meant other professionals and friends and family were not able to report concerns about a child’s health
• Widening of socio-economic inequalities (including unemployment and reduced household earning capacities) means that certain members of society are not able to purchase a balanced,good quality nutrition for their children
I accept that these are not factors that have been scientifically tested, but nevertheless the increase in the incidents of anaemia and the deaths that are arising are a matter of concern
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of other professionals, friends and family to report concerns about children’s health
Wider context from the report “During the evidence it became clear that in the Yorkshire & Humber region there has been an increased incidence of severe nutritional anaemia in 2020 in a paediatric setting, resulting in 2 deaths, Maya’s death being one of the two. The witness had not seen any deaths previously in her career.
The witness had consulted 9 colleagues over the data. They surmise that a number of factors arising indirectly from the pandemic may explain the findings:
• The “stay at home” message resulted in less 1 to 1 consultations, so health professionals were not able to spot the signs of anaemia
• Limitation of social contact meant other professionals and friends and family were not able to report concerns about a child’s health
• Widening of socio-economic inequalities (including unemployment and reduced household earning capacities) means that certain members of society are not able to purchase a balanced,good quality nutrition for their children
I accept that these are not factors that have been scientifically tested, but nevertheless the increase in the incidents of anaemia and the deaths that are arising are a matter of concern
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient one-to-one consultations for health professionals to identify signs of anaemia in children
Wider context from the report “During the evidence it became clear that in the Yorkshire & Humber region there has been an increased incidence of severe nutritional anaemia in 2020 in a paediatric setting, resulting in 2 deaths, Maya’s death being one of the two. The witness had not seen any deaths previously in her career.
The witness had consulted 9 colleagues over the data. They surmise that a number of factors arising indirectly from the pandemic may explain the findings:
• The “stay at home” message resulted in less 1 to 1 consultations, so health professionals were not able to spot the signs of anaemia
• Limitation of social contact meant other professionals and friends and family were not able to report concerns about a child’s health
• Widening of socio-economic inequalities (including unemployment and reduced household earning capacities) means that certain members of society are not able to purchase a balanced,good quality nutrition for their children
I accept that these are not factors that have been scientifically tested, but nevertheless the increase in the incidents of anaemia and the deaths that are arising are a matter of concern
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Increased incidence of severe nutritional anaemia and associated deaths in children
Wider context from the report “During the evidence it became clear that in the Yorkshire & Humber region there has been an increased incidence of severe nutritional anaemia in 2020 in a paediatric setting, resulting in 2 deaths , Maya’s death being one of the two. The witness had not seen any deaths previously in her career.
The witness had consulted 9 colleagues over the data. They surmise that a number of factors arising indirectly from the pandemic may explain the findings:
• The “stay at home” message resulted in less 1 to 1 consultations, so health professionals were not able to spot the signs of anaemia
• Limitation of social contact meant other professionals and friends and family were not able to report concerns about a child’s health
• Widening of socio-economic inequalities (including unemployment and reduced household earning capacities) means that certain members of society are not able to purchase a balanced,good quality nutrition for their children
I accept that these are not factors that have been scientifically tested, but nevertheless the increase in the incidents of anaemia and the deaths that are arising are a matter of concern
” 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 Available data does not show a significant national or regional increase in iron deficiency anaemia diagnoses.
Verbatim wording from the response “NHSEI advises that data relating to diagnoses of iron deficiency anaemia¹ does not show any significant increase nationally or regionally. The numbers regionally, by month, are generally quite low and can vary considerably month by month. However, the overall trend shows no significant increase. I hope this information is helpful.” Source location 2021-0316-Response-from-Department-of-Health-Social-Care_Published
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 healthy-diet promotion efforts are considered sufficient; no policy specifically targeting nutritional anaemia will be introduced.
Verbatim wording from the response “The Government does not have any plans to introduce policies to specifically target nutritional anaemia in children. However, the Government’s efforts to promote a healthy balanced diet for children contribute to this goal by encouraging the intake of food rich in nutrients essential to preventing anaemia, such as iron.” Source location 2021-0316-Response-from-Department-of-Health-Social-Care_Published
Open published response
10 Sep 2021 Lee Ryan Thrumble · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 1 Failure to make NOMIS training compulsory for clinicians working with prisoners 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
Lee Ryan Thrumble · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lee Ryan Thrumble was a serving prisoner who suspended himself by the neck in a cell at HMP Rochester on 17 April 2018 and died the following day. The inquest found that failures to meet his mental health needs and to respond adequately to deteriorating behaviour contributed to his death. The principal concern was that incomplete access by clinical staff to NOMIS information, linked to non-compulsory training, could prevent prisoners’ mental health needs and risks from being identified and managed appropriately.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to make NOMIS training compulsory for clinicians working with prisoners
Wider context from the report “I am concerned that:
(a) Lee died partly because of a lack of training which prevented staff from accessing and reviewing information .
(b) NOMIS contains important information that can be of use to clinical staff when looking after prisoners .
(c) Not all nurses can access NOMIS because it is not a compulsory part of their training .
(d) The NOMIS training is already available, can be completed online and access to NOMIS can be gained within two days.
(e) If the current situation continues there is a risk that prisoners may die as a result.
This situation should be reviewed and consideration given to whether NOMIS training should be made compulsory for clinicians working within prisons in England and Wales.
” Open source report
9 Sep 2021 Joshua SAHOTA · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1 Failure to communicate patient-specific restricted items to families and friends before ward visits 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
Joshua SAHOTA · 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
Joshua Sahota, a 25-year-old man, died on 9 September 2019 after being found with a plastic carrier bag over his head and a bed sheet around his neck while an inpatient on a mental health ward. The report raised concerns about ineffective communication to families and friends regarding items classified as restricted, including plastic carrier bags, and the inquest identified concerns including insufficient staffing, insufficient observations and one-to-one support, inadequate documentation, no psychologist availability, and an unclear restricted-items policy.
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 communicate patient-specific restricted items to families and friends before ward visits
Wider context from the report “relate to the communication of what are ‘restricted and contraband items’ to the family and friends of a patient, before those family and friends visit the mental health ward.
This would be particularly important for a family or friends first visit to the ward.
The court was told that there are signs up at the entrance of the ward detailing items that are ‘contraband’. These items are not allowed onto the ward in any circumstances.
This makes it clear to all visitors what cannot be taken onto the ward in any circumstances.
However, the court was told that a ‘restricted item’ regime also exists, under which patients are risk assessed, with some being allowed particular items (such as mobile phone charger leads, laptop leads, belts and lighters), whilst others are not.
From the evidence we heard in this case, we know that Josh’s clothes were taken onto the ward in a plastic carrier bag, which at the time was a restricted item.
We heard that the bag was emptied, the contents were searched, re-packed and then taken to Josh’s room.
From the investigation into this matter, it is apparent that firstly, that had the family known that a plastic carrier bag was a restricted item, it would not have been taken to the hospital in the first instance.
Secondly, that had the family been aware that a plastic carrier bag was a restricted item, even though they may have used one to deliver Josh’s clothes, they would have drawn staff attention to the bag when it was subsequently taken and left in Josh’s room.
During the evidence no clear system or procedure was identified, for a family to be notified of any particular items that have been deemed ‘restricted’ items for their loved one to have in their possession.
There was therefore no effective communication with the family regarding what items were, and what items were not, allowed onto the ward in Josh’s case.
I am therefore concerned that families and friends of current in-patients, may still inadvertently take a particular item onto ward, or be aware that their loved one has a particular item in their possession, yet be totally unaware that that particular item has been risk assessed as a restricted item for their loved one.
It is known that families and friends of in-patients can play a vital role in their care, treatment and recovery. However, without knowing what have been deemed ‘restricted items’ for their loved one, the ability to assist in keeping their loved one safe whilst an in-patient, is effectively removed from those family and friends.
” Open source report
6 Sep 2021 Glenda May Logsdail · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 7 Inhibitory hierarchical structure preventing staff from speaking up during emergencies View source Lack of awareness of the capnography safety campaign among anaesthesia staff View source Inappropriate delegation of irrelevant tasks during anaesthetic emergencies View source Failure to perform confirmatory checks of endotracheal tube placement View source Failure to reassess possible correctable causes when the patient fails to improve View source Inconsistent ventilator display configurations across clinical areas View source Failure of emergency team leadership, role clarity and coordination 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
Glenda May Logsdail · 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
Glenda May Logsdail was admitted with acute appendicitis and underwent emergency surgery. During induction of anaesthesia, an endotracheal tube was misplaced in the oesophagus and this was not recognised for a prolonged period, resulting in hypoxia, cardiac arrest, irreversible brain damage and her death. Concerns included failures to confirm tube placement, fixation on an incorrect diagnosis, inadequate team leadership and communication during the emergency, and inconsistent ventilator display configurations.
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 Inhibitory hierarchical structure preventing staff from speaking up during emergencies
Wider context from the report “(5) There was evidence of an inhibitory hierarchical structure which prevented others shouting out . This is despite the fact that I found Dr ████████ to be a mild mannered, gentle and reflective witness.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the capnography safety campaign among anaesthesia staff
Wider context from the report “(1) I was concerned to find that the anaesthetising Consultant Anaesthetist was not aware of the Royal College of Anaesthetists campaign video “Capnography in Cardiac Arrest: No Trace = Wrong Place” .
(2) I became even more concerned when towards the end of the Inquest when I was hearing evidence on the Incident Investigation Report the author, told me he had not been aware of the campaign himself until this incident .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inappropriate delegation of irrelevant tasks during anaesthetic emergencies
Wider context from the report “(7) The panic and chaos led to an inappropriate delegation of an irrelevant task to a Consultant Anaesthetist who attended to assist who eventually was the one to realise the ET tube was misplaced. This distracted her for a minute or two adding to the time when Mrs Logsdail was not ventilated .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to perform confirmatory checks of endotracheal tube placement
Wider context from the report “(3) As Mrs Logsdail’s condition deteriorated there was no evidence that any confirmatory checks, notably looking for the presence of a capnography trace or expiratory misting, were done to check correct placement of the endo tracheal tube .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 reassess possible correctable causes when the patient fails to improve
Wider context from the report “(4) As Mrs Logsdail deteriorated Dr ████████ erroneously fixated on a diagnosis of anaphylaxis being responsible for the collapse. That fixation was contagious and appeared to compromise the assessments by other staff members who attended to help. Dr ████████ did not go back to basics and consider A(airway), B (breathing), C (circulation) to work his way through possible correctable causes . He told me frankly that he became more and more fixated on anaphylaxis as the cause. Despite treatment for anaphylaxis and Mrs Logsdail’s failure to improve he persisted with this as the diagnosis . His certainty in his diagnosis inhibited other staff members from effectively contemplating other causes until the arrival of another Consultant Anaesthetist. I accept entirely that he was not behaving in a dismissive or aggressive manner. He simply conveyed an infectious certainty which hindered other team members challenging him when several could see that Mrs Logsdail was increasingly cyanosed and in desperate straits.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistent ventilator display configurations across clinical areas
Wider context from the report “(8) I heard that there were variable and different configurations with respect to the displays on the ventilators in different theatres and anaesthetic rooms and ITU through the hospital . This was confusing for staff and had potential to put patients at 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 Failure of emergency team leadership, role clarity and coordination
Wider context from the report “(6) There was panic and chaos in the anaesthetic room. There was considerable confusion as to roles and there was an absence of a leader dealing with the emergency . Dr ████████ was the natural leader but I found that he was effectively blind to what needed to be done – to check the capnograph and to reintubate. Individual staff members took on roles independently in the cardiac arrest. That is to be commended on an individual level but it betrays a fundamental lack of direction and control of the situation and bodes poorly for management of future life threatening emergencies. The team malfunctioned and did not operate as a team .
” 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 Standardising multiparameter monitor displays could remove necessary flexibility, create unnecessary monitoring requirements and adversely affect patient safety.
Verbatim wording from the response “The displays of the multiparameter monitors used during anaesthesia have to be customisable so they can accommodate the different types of monitoring devices, which may be required for different types of anaesthesia and surgery being undertaken. This is necessary because the needs of the patient vary according to the complexity of the surgery being undertaken. If there was standardisation, this would either remove this flexibility or require unnecessary monitoring parameters where they are not essential. This in turn would have unintended impacts on patient safety.” Source location 2021-0295-Response-from-Department-of-Health-Social-Care_Published
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 Individual NHS trusts are responsible for delivering emergency simulation and team-based training, subject to available resources and clinical trainer time.
Verbatim wording from the response “In relation to your concerns about multi-disciplinary team working in an emergency situation, you may wish to note that specific simulation-based training for emergency skills and team-based drills in specialised areas of clinical practice, such as the operating theatre, is the responsibility of, and delivered by, individual NHS trusts, based on the” Source location 2021-0295-Response-from-Department-of-Health-Social-Care_Published
Open published response
6 Sep 2021 Mark Holden · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 NICE guidance failing to address Covid-19-related D-dimer and clotting risks View source Failure of the Lorenzo electronic system to trigger alerts for markedly raised D-dimer results View source Failure to provide physical examination during telephone GP consultations where clinically needed 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
Mark Holden · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mark Thomas Holden was diagnosed with Covid-19 and subsequently developed a deep vein thrombosis in his left calf, which led to a pulmonary embolus. He collapsed at home on 26 February 2021 and attempts to resuscitate him were unsuccessful. Concerns included the lack of a face-to-face GP examination, failure of the electronic system to alert staff to a markedly raised D-Dimer, and NICE guidance not addressing Covid-19-related clotting risks.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation NICE guidance failing to address Covid-19-related D-dimer and clotting risks
Wider context from the report “3. The inquest heard that there will often be a raised D- Dimmer with Covid-19 and that in addition there is an increased risk of clots with Covid-19. The evidence before the inquest was that the existing NICE guidance used by clinicians does not deal with the Covid-19 aspects/ recognised risks .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of the Lorenzo electronic system to trigger alerts for markedly raised D-dimer results
Wider context from the report “2. The D-Dimmer of over 10,000 did not trigger an alert on the Lorenzo electronic system due to how it was reported and the configuration of Lorenzo at that time at the Trust . The Trust have taken steps to change how the reports are input into Lorenzo to ensure a raised D- Dimmer such as this triggers an alert. It was unclear if that learning has been shared across the NHS to other trusts who use Lorenzo to ensure that alerts are triggered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 physical examination during telephone GP consultations where clinically needed
Wider context from the report “1. The appointment with the GP was via telephone due to Covid. As a result, there was no examination of Mr Holden and no opportunity to identify the DVT which was present at the time of the telephone consultation .
” Open source report
1 Sep 2021 William Buchanan · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 1 Lack of suitability and competence assessments for elderly mobility scooter purchasers 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
William Buchanan · 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
William Buchanan sustained multiple rib fractures in an unwitnessed incident involving his mobility scooter at home after it was delivered. He developed pneumonia and died in hospital; the principal concern was that people can purchase mobility scooters without an assessment of their suitability or competence to use them, potentially giving rise to 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 Lack of suitability and competence assessments for elderly mobility scooter purchasers
Wider context from the report “(1) Lifestyle and Mobility completed a home assessment including a suitability questionnaire as Mr Buchanan was obtaining his scooter through the Mobility scheme. If clients purchase a scooter privately, the company has a detailed questionnaire they complete which has been designed in conjunction with the British Healthcare Trades Association. However, I was very concerned to learn that elderly individuals can purchase mobility scooters online or in other stores without any assessment whatsoever being completed to assess their suitability or competence to use one . This gives rise to a concern that future deaths could occur if action is not taken.
” Open source report
27 Aug 2021 Fadhia SEGULEH · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to enable relevant family input during emergency mental health assessment View source Telephone-only GP assessments of mental health risk and need View source Lack of coordinated information sharing between professionals involved in mental health care 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
Fadhia SEGULEH · 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
Fadhia Seguleh was receiving treatment for anxiety and depression when she was found unresponsive, attached to a ligature at her home on 24 February 2021. The concerns included fragmented care and inadequate information sharing between NHS mental health services, her GP and private therapy provider, telephone-only mental health assessments during Covid, and her attending A&E alone during a previous mental health crisis without family input.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to enable relevant family input during emergency mental health assessment
Wider context from the report “3. The inquest heard evidence that she had on a previous occasion been taken to A and E due to concerns that she would take her own life/self-harm. Due to Covid she had to go alone to A and E and was assessed alone without input from her family who were aware of the full picture . The experience of attending alone whilst experiencing mental health issues was deeply stressful for her and meant that she had been unsupported by her family at a time of crisis . In addition, the quality of information available was limited as a result of her being there alone .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Telephone-only GP assessments of mental health risk and need
Wider context from the report “2. As a consequence of Covid all of the assessments of her by her GP in relation to her mental health were done via telephone . Prior to Covid it was likely that they would have been done face to face. It was accepted that assessments of mental health risk and understanding of need was far easier to assess face to face .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 information sharing between professionals involved in mental health care
Wider context from the report “1. The inquest heard evidence that she was being treated by the NHS Mental Health Trust, GP and through private therapy provided by her employer. As a consequence, the professionals treating her did not have a full picture of disclosures made by her and professionals operated in silos . There was no protocol in place for information sharing between those involved and no policy to guide appropriate steps to obtain information . A query raised with the GP would have enabled a clearer picture of the issues to be held by the private provider. Information sharing would have provided a more rounded understanding of risks.
The operation in silos meant that the treatment plan put in place by the mental health team including medication was not fully understood by the GP and was altered following a consultation between the GP and Fadhia. Information sharing between agencies would have allowed for a more detailed assessment of risk in the situation.
” Open source report
Concerns raised 4 Failure of VTE risk assessments to provide comprehensive and clear assessment criteria View source Lack of consistency in VTE risk assessments between hospitals View source Lack of national guidance on bilateral leg swelling in DVT diagnostic profiling View source Failure of hospital discharge letters to communicate prophylactic anticoagulation requirements clearly View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Cherry Rosemary 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
Cherry Rosemary Dunn died after an acute episode at Kirby Ward on 5 November 2018, with the inquest recording pulmonary embolism, deep vein thrombosis and immobility as causes of death. Concerns included bilateral leg swelling not prompting sufficient consideration of deep vein thrombosis, ambiguity in VTE risk assessments, and confusing hospital discharge letters that affected decisions about prophylactic anticoagulation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of VTE risk assessments to provide comprehensive and clear assessment criteria
Wider context from the report “• VTE risk assessment form
The VTE risk assessment used at the time of Mrs Dunn’s death was not as comprehensive as it could have been . Leicestershire Partnership NHS Trust have made improvements to their original form (previous and current ones attached to this report). However, a concern remains that it is still not as clear as it could be, and different conclusions could be arrived at depending on the doctor completing the form . This would then impact on whether prophylactic anticoagulation is prescribed. Therefore, there is a concern that this is a problem nationally and different hospitals use different VTE risk assessments that can be confusing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of consistency in VTE risk assessments between hospitals
Wider context from the report “• VTE risk assessment form
The VTE risk assessment used at the time of Mrs Dunn’s death was not as comprehensive as it could have been. Leicestershire Partnership NHS Trust have made improvements to their original form (previous and current ones attached to this report). However, a concern remains that it is still not as clear as it could be, and different conclusions could be arrived at depending on the doctor completing the form. This would then impact on whether prophylactic anticoagulation is prescribed. Therefore, there is a concern that this is a problem nationally and different hospitals use different VTE risk assessments that can be confusing .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on bilateral leg swelling in DVT diagnostic profiling
Wider context from the report “• Clinical indications of VTE
Bilateral leg swelling overshadowed the consideration for a DVT and without guidance to all doctors nationally, bilateral leg swelling will remain a problem for the diagnostic profiling of a DVT .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital discharge letters to communicate prophylactic anticoagulation requirements clearly
Wider context from the report “• Hospital discharge letters
The discharge letter used when Mrs Dunn was transferred from one hospital setting to another (attached) was confusing . The doctor at the receiving hospital read it to mean that prophylactic anticoagulation was not required and therefore the doctor was persuaded in part by this even though the risk assessment that was completed had a positive result.
The University Hospitals of Leicester NHS Trust have now revised their discharge letter (attached) which more clearly reflects NICE Guidance and removes the previous confusion.
However, there is a concern that the original discharge letter is used in other Trusts and therefore the confusion remains in other areas with the risk of what happened in this case happening elsewhere .
” Open source report
24 Aug 2021 Stanislaw Wieslaw ZIELINSKI · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Delays in offering mental health support View source Failure of GP consultation arrangements to support effective communication about deteriorating health View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stanislaw Wieslaw ZIELINSKI · 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
Stanislaw Wieslaw Zielinski’s mental health deteriorated after he reported anxiety and insomnia, with care provided through telephone GP appointments and delays in mental health support. On 20 October 2020, he fell from an upstairs window and sustained multiple fractures and a subdural haematoma; he later died from a cardiac arrest due to a pulmonary embolism following hospitalisation and surgery. The concerns included difficulties communicating his deteriorating condition through telephone consultations and delays in receiving mental health support during the Covid-19 period.
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 offering mental health support
Wider context from the report “2. Mental health services were experiencing delays due to operating under the constraints of Covid and staffing issues . As a result there was a delay in offering him support which would have assisted him. The inquest heard that the existing challenges pre Covid for mental health services had been exacerbated by Covid due to an increased need for their services in part as a result of the impact on mental health of isolation during lockdown.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 GP consultation arrangements to support effective communication about deteriorating health
Wider context from the report “1. Pre Covid Mr Zielinski would have been seen face to face rather than through a series of telephone consultations. The inquest heard that he and his family struggled to communicate with the GP to explain his deteriorating health position as a result of how his GP practice was delivering health care . The inquest heard evidence that as a consequence his deteriorating picture was not fully understood by his GP and he was additional anxious as a result of an inability to express his concerns in person.
” 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 provide targeted support for groups most affected by the pandemic.
Verbatim wording from the response “While emerging from the crisis period resulting from Covid-19, the Department continues to monitor the impact of the pandemic and adjust policy and investment priorities where necessary. As part of the Government’s commitment to build back better, we have published our Mental Health Recovery Action Plan³, backed by an additional £500million for this financial year, to ensure that the right support is in place. The plan aims to respond to the impact of the pandemic on mental health of the public, specifically targeting groups which have been most affected including those with severe mental illness, young people, and frontline staff.” Source location 2021-0277-Response-from-Department-of-Health-Social-Care_Published.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand adult mental health services, including psychological therapies, community mental health, crisis services and suicide prevention programmes.
Verbatim wording from the response “As part of this investment, we have committed to accelerate key commitments in the NHS Long Term Plan, including:” Source location 2021-0277-Response-from-Department-of-Health-Social-Care_Published.pdf
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 Monitor the pandemic’s impact on mental health and adjust policy and investment priorities where necessary.
Verbatim wording from the response “While emerging from the crisis period resulting from Covid-19, the Department continues to monitor the impact of the pandemic and adjust policy and investment priorities where necessary. As part of the Government’s commitment to build back better, we have published our Mental Health Recovery Action Plan³, backed by an additional £500million for this financial year, to ensure that the right support is in place. The plan aims to respond to the impact of the pandemic on mental health of the public, specifically targeting groups which have been most affected including those with severe mental illness, young people, and frontline staff.” Source location 2021-0277-Response-from-Department-of-Health-Social-Care_Published.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Grow the mental health workforce to deliver the accelerated service commitments.
Verbatim wording from the response “As part of this investment, we have committed to accelerate key commitments in the NHS Long Term Plan, including:” Source location 2021-0277-Response-from-Department-of-Health-Social-Care_Published.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand support in children and young people’s mental health services through the committed investment.
Verbatim wording from the response “As part of this investment, we have committed to accelerate key commitments in the NHS Long Term Plan, including:” Source location 2021-0277-Response-from-Department-of-Health-Social-Care_Published.pdf
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 referral to Improving Access to Psychological Therapies and offer of a first appointment were within expected national timeframes.
Verbatim wording from the response “My officials understand from NHSEI that Mr Zielinski’s referral to local Improving Access to Psychological Therapies, and offer of a first appointment were within the expected national timeframes.” Source location 2021-0277-Response-from-Department-of-Health-Social-Care_Published.pdf
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 guidance, procedures and resources are considered sufficient to support safe remote general practice consultations alongside face-to-face appointments.
Verbatim wording from the response “Throughout the pandemic, NHS England and NHS Improvement (NHSEI) provided guidance to general practice and continually updated standard operating procedures to ensure that changing services could operate safely. NHSEI set out clear expectations that general practices offer face to face appointments alongside remote appointments (telephone and online), and that clinical appropriateness and patient preference should be taken into account to determine the most appropriate consultation method. NHSEI has also supported general practices in how best to” Source location 2021-0277-Response-from-Department-of-Health-Social-Care_Published.pdf
Open published response
23 Aug 2021 Maurice Leech · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to provide physical examination during GP consultations View source Lack of NICE guidance for consistent management of femur fractures in elderly patients View source Lack of support for vulnerable patients during hospital assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Maurice Leech · 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
Maurice Leech had an accidental fall at Thorncliffe Grange Nursing Home, later diagnosed as a femur fracture, and died there on 30 April 2020 after being discharged for palliative care. Concerns included a telephone GP review without physical examination, lack of support when he attended hospital during Covid, the missed fracture, and the absence of NICE guidance for managing femur fractures in elderly patients, including pain management.
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 physical examination during GP consultations
Wider context from the report “1. The inquest heard evidence that pre Covid Mr Leech would have been examined face to face by the GP rather than a telephone consultation without an examination . The evidence indicated that a physical examination would probably have resulted in Mr Leech being referred back to hospital at an earlier stage.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of NICE guidance for consistent management of femur fractures in elderly patients
Wider context from the report “3. The inquest heard that he was in significant pain from the fracture to the femur. Unlike the position relating to a fracture to the neck of femur there is no NICE guidance for treatment of such fractures to ensure a consistent approach to management of them in the elderly across the NHS . This included in Mr Leech’s case how to effectively manage his pain and the impact of that on his overall health .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of support for vulnerable patients during hospital assessment
Wider context from the report “2. Mr Leech was very vulnerable and a poor historian. Due to Covid he was sent alone to hospital and seen alone there . The evidence before the inquest was that if support had been available a more accurate picture of his baseline and needs would have assisted staff in treating him and potentially identifying that he should not be discharged back to the care home and that a fracture would not have been missed.
” 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 Existing guidance, procedures, training and safety resources are considered sufficient to support safe remote general practice consultations.
Verbatim wording from the response “Throughout the pandemic, NHSEI provided guidance to general practice and continually updated standard operating procedures to ensure that changing services could operate safely. NHSEI set out clear expectations that general practices offer face to face appointments alongside remote appointments (telephone and online), and that clinical appropriateness and patient preference should be taken into account to determine the most appropriate consultation method. NHSEI has also supported general practices in how best to communicate with their population on how to access services. Further details on guidance and standard operating procedures can be found on the NHSEI website¹.” Source location 2021-0279-Response-from-Department-of-Health-Social-Care_Published.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There is not a lack of guidance on periprosthetic femoral fracture treatment, fracture pain management or palliative care.
Verbatim wording from the response “In relation to your concern about guidance for the treatment of fractures to the femur, you may wish to note that while NICE Clinical Guideline 124: Hip fracture: management⁴, does not make specific recommendations on the management of this type of fracture (periprosthetic), it does cover the use of analgesia (see section 1.4) and multidisciplinary management (section 1.8) of people with hip fracture. I am advised by NICE that it is reasonable to expect that Clinical Guideline 124 could be applied to people with periprosthetic femoral fracture, such as Mr Leech.” Source location 2021-0279-Response-from-Department-of-Health-Social-Care_Published.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local NHS Trusts are responsible for determining hospital visiting arrangements within national principles and their own safety assessments.
Verbatim wording from the response “Since the end of the national lockdown in England, visiting in hospitals is now subject to the discretion of local NHS Trusts, based on the national principles, which will make their own assessment as to the visiting arrangements that can safely be put in place. Careful hospital visiting policies remain appropriate while COVID-19 continues to be in general circulation and organisations can exercise discretion where COVID-19 rates are higher. The health, safety and wellbeing of patients, communities and staff remains the priority.” Source location 2021-0279-Response-from-Department-of-Health-Social-Care_Published.pdf
Open published response
17 Aug 2021 Roland Stannard · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 2 Insufficient care-home staff knowledge and training to operate specialist pressure-sore equipment View source Unclear thresholds for assessing need for nursing care when complex medical equipment is required View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Roland Stannard · 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
Roland Stannard died at West Suffolk Hospital after developing a serious sacral pressure sore while resident at Chiltern Meadows Care Home. The report identified concerns about miscommunication over his medication, inadequate care while he remained on a commode overnight, and care staff’s insufficient training to operate specialist equipment intended to prevent or treat pressure sores. It also raised concern about when a care-home resident’s needs should prompt an assessment for nursing care rather than continued social care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient care-home staff knowledge and training to operate specialist pressure-sore equipment
Wider context from the report “Specifically, once Mr Stannard’s sacral sore had occurred, due to staff inexperience and lack of training , the equipment provided to reduce the further development of his sacral sore was either not utilised, or if utilised sometimes used incorrectly .
Residential homes, such as the one Mr Stannard was resident in, provide social and personal care, but medical treatment is provided by visiting medical professionals. In Mr Stannard’s case his nursing care was provided by visiting District Nursing staff.
It was clear that once Mr Stannard had begun to develop a sacral sore, specialist equipment was made available by the District Nurses and provided within short timescales (in one instance the equipment identified as being needed, was delivered and fitted within a 4-hour period).
This equipment included a high-grade air alternating mattress and an automatic lateral turning system.
However, we were told in evidence that when a District Nurse next visited, the air bed was found to be set too high for someone of Mr Roland’s weight (and would therefore not be therapeutic as the bed would be too hard) and that the independent automatic lateral turning system had been unplugged.
In relation to the unplugged device, the nurse was told that care staff were unsure of the correct mode of operation for this device so they had contacted the manufacturer and were erroneously told it could not be used in Mr Stannard’s circumstances.
Both issues were identified and rectified when a District Nurse visited Mr Stannard at home. However, the District Nurses did not necessarily visit every day and due to CoVID19 restrictions in place at the time, also provided online ‘virtual’ consultations.
I am therefore concerned in relation to the provision of specialist equipment to any care home setting, in which the care home staff have insufficient knowledge and training on how to properly operate this specialist equipment . My concern is that in the absence of adequately trained staff, equipment designed to reduce the threat of developing pressure sores (or to aid the treatment of them), will continue to either not be used at all, or if used, used incorrectly .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unclear thresholds for assessing need for nursing care when complex medical equipment is required
Wider context from the report “I am further concerned as to what point an assessment should be made to identify whether an individual needs nursing care, rather than continuing social care , and whether the provision of some types of complex medical equipment should prompt such an assessment .
” 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 specialist pressure-relieving equipment would not normally trigger a nursing needs assessment because such equipment is commonplace in care settings.
Verbatim wording from the response “The East Suffolk and North Essex NHS Foundation Trust has advised that the prescribing of specialist equipment, such as pressure relieving devices, would not normally trigger the need for a nursing needs assessment as this equipment is commonplace in community and residential care settings. Community nurses visiting patients would check at each visit the appropriateness and use of the equipment and if concerned, would make a safeguarding referral. A nursing needs assessment is more likely to be triggered by other factors such as a significant deterioration in the patient’s condition or complex care needs.” Source location 2021-0274-Response-from-Dept.-of-Health-and-Social-Care_Published
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 registered care provider is responsible for ensuring staff have the skills, knowledge and experience to deliver safe care.
Verbatim wording from the response “It is the responsibility of the CQC registered provider of care to make sure that staff have the skills, knowledge and experience to deliver safe, effective care that meets people’s needs. If, for example, a resident is at risk of pressure ulcers, the provider is required to ensure that the staff have the appropriate training to look after the person effectively. These responsibilities are set out in The Health and Social Care Act 2008 (Regulated activities) Regulations 2014 (particularly in this instance, regulations 12; 15 and 18)¹.” Source location 2021-0274-Response-from-Dept.-of-Health-and-Social-Care_Published
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 relevant clinical commissioning group is responsible for ensuring appropriate NHS-funded nursing care assessments are carried out.
Verbatim wording from the response “In relation to your concern about the point at which an assessment of nursing care needs should be made, it may be helpful to note that how and when a person should be assessed for NHS-Funded Nursing Care and NHS Continuing Healthcare is explained in the National Framework³, published in 2018. It is the responsibility of the relevant clinical commissioning group (CCG) to ensure that an assessment for NHS-Funded Nursing Care is carried out where it appears that a person may have a need for nursing care and that eligibility for NHS Continuing Healthcare is considered prior to any decision on eligibility for NHS-Funded Nursing Care.” Source location 2021-0274-Response-from-Dept.-of-Health-and-Social-Care_Published
Open published response
13 Aug 2021 Mr Stuart Tokam · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Lack of a process to triage referral acuity and expedite clinical assessments where necessary View source Delays in arranging clinical assessments 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
Mr Stuart Tokam · 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 Stuart Tokam, who had a documented history of depressive illness and two previous attempts to take his own life, died after hanging himself from railings at Dalaman Airport, Turkey, on 18 September 2020. Concerns included an unacceptable delay in arranging a clinical assessment and the apparent absence of a process to triage referral acuity and expedite assessment where necessary.
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 process to triage referral acuity and expedite clinical assessments where necessary
Wider context from the report “2. There appears to have been no process in place to triage the acuity of a referral and expedite a clinical assessment where necessary .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 arranging clinical assessments
Wider context from the report “1. There was an unacceptable delay in arranging a clinical assessment of Mr Tokam.
” Open source report
10 Aug 2021 Alice Beatrice Pettersson · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 3 Lack of national guidelines for the early evaluation and management of infants and children with achondroplasia View source Insufficient awareness among general paediatric clinical teams of achondroplasia-associated risks and urgent referral scenarios View source Lack of a designated referral pathway for children with achondroplasia 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
Alice Beatrice Pettersson · 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
Alice Beatrice Pettersson died at Great Ormond Street Hospital London after suffering cord compression due to undiagnosed foramen magnum stenosis associated with achondroplasia. The report identified concerns about the absence of designated referral pathways and national guidance, and about the need for prompt specialist assessment, MRI scanning and sleep studies.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidelines for the early evaluation and management of infants and children with achondroplasia
Wider context from the report “No NICE or other national guidelines are currently available for the early evaluation and management of infants and children with Achondroplasia .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 awareness among general paediatric clinical teams of achondroplasia-associated risks and urgent referral scenarios
Wider context from the report “There is no designated referral pathway for children with achondroplasia and general paediatric clinical teams are not always aware of the associated risks or clinical scenarios which should prompt immediate referral to centres of excellence .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a designated referral pathway for children with achondroplasia
Wider context from the report “There is no designated referral pathway for children with achondroplasia and general paediatric clinical teams are not always aware of the associated risks or clinical scenarios which should prompt immediate referral to centres of excellence.
” Open source report
Concerns raised 4 Lack of national guidance for A&E clinicians on when to administer possible antidotes for toxic substances View source Failure to use Serious Incident Reviews and internal investigations to learn lessons from suicide cases View source Lack of national guidance and timely information for mental health practitioners about sodium nitrate/nitrite risks View source Failure to disseminate information about sodium nitrate/nitrite risks beyond immediately involved colleagues View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
JAMES MICHAEL NOWSHADI · 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 Michael Nowshadi died after ingesting a substance he had obtained online to end his life, suffering cardiac arrest and being pronounced dead on 1 April 2020. Concerns included insufficient national guidance and information-sharing about the risks of sodium nitrate/nitrite, missed opportunities for learning from the Serious Incident Review, and a lack of guidance for emergency clinicians on the use of methylene blue in cases involving cardiac arrest.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for A&E clinicians on when to administer possible antidotes for toxic substances
Wider context from the report “3. The inquest heard evidence from a senior Accident & Emergency doctor about the information available from the National Poisons Information Service to emergency departments who encounter patients who have ingested ████████. This included information about the potential availability of an antidote, ‘methylene blue’. However, there is apparently no national guidance about the appropriate use of the antidote in cases involving cardiac arrest and whether attempts should be made to administer it in such cases . I am concerned that there is a risk of future fatalities if A&E clinicians do not have access to comprehensive and up-to-date information about toxic substances and their possible antidotes to know when – and when not – to administer 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 use Serious Incident Reviews and internal investigations to learn lessons from suicide cases
Wider context from the report “2. The family raised concerns about the risks of ████████ in suicides as part of the Serious Incident Review undertaken by the Trust but this section was omitted from the final report at the direction of the SIR review panel. This meant that there was a missed opportunity for the Trust to reflect on lessons that may properly be learned from James’ death, an omission which they now appear to be taking steps to remedy. However, I am concerned that there is a risk of future fatalities at a national level if Mental Health Trusts are not using Serious Incident Reviews and other internal investigations to learn lessons from suicide cases, including about the risks presented by sodium nitrate/nitrite .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance and timely information for mental health practitioners about sodium nitrate/nitrite risks
Wider context from the report “1. There does not appear to be any national guidance available to psychiatrists and mental health practitioners dealing with possible ████████ cases . Those involved in James’ care made insufficient effort to research or evaluate the potential risks and consequences of James obtaining and using the ████████ to end his life and any information that was obtained from brief internet searches was not disseminated to colleagues beyond those immediately involved in James’ care only. I am concerned that there is a risk of future fatalities if mental health practitioners do not have ready access to timely and up-to-date information about the risks associated with sodium nitrate/nitrite .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 disseminate information about sodium nitrate/nitrite risks beyond immediately involved colleagues
Wider context from the report “1. There does not appear to be any national guidance available to psychiatrists and mental health practitioners dealing with possible ████████ cases. Those involved in James’ care made insufficient effort to research or evaluate the potential risks and consequences of James obtaining and using the ████████ to end his life and any information that was obtained from brief internet searches was not disseminated to colleagues beyond those immediately involved in James’ care only . I am concerned that there is a risk of future fatalities if mental health practitioners do not have ready access to timely and up-to-date information about the risks associated with sodium nitrate/nitrite.
” Open source report
20 Jul 2021 Vinnie William Ord Dodds · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 4 Lack of standardised counselling about fatal risks associated with shoulder dystocia View source Lack of clear guidance on the optimal timing of glucose tolerance testing View source Failure to include the risk of death from shoulder dystocia in patient information View source Lack of national guidance on management and counselling thresholds for large babies in pregnancy 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
Vinnie William Ord Dodds · 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
Vinnie William Ord Dodds died at Sunderland Royal Hospital on 14 April 2020 after major shoulder dystocia was recognised following a forceps delivery; he could not be successfully resuscitated. The concerns related to antenatal care, including the lack of national guidance for managing large babies, the content of counselling about shoulder dystocia risks, the timing of glucose tolerance testing, and the omission of the risk of death from shoulder dystocia in current patient information.
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 standardised counselling about fatal risks associated with shoulder dystocia
Wider context from the report “Although shoulder dystocia is a medical emergency for which staff are trained, it was the elements of the mother’s antenatal care which gave rise to concerns notwithstanding the obvious impact of the pandemic.
The Trust carried out and acted on a full review. However, there are concerns of wider significance: -
1. There is no national guidance for the management of large babies in pregnancy, unless diabetes is present, so it may not be possible to produce a safety recommendation to advise mothers with a suspected large baby.
a) should counselling/management be based on 'macrosomia' (i.e. weight estimated >4500g for diabetes and >5000g for non-diabetic) or alternatively should it now be applied to all babies estimated to be >90th centile by scan >34 weeks?
b) in counselling women about risk of shoulder dystocia in LGA, should this include formal mention of the rare risk of foetal death and if women are to be fully informed should this be balanced by the rare risk of maternal death with an elective Caesarean section (the only other mode of delivery to be considered)?
c) in fact, point b is highly relevant to counselling ALL women about the risks associated with shoulder dystocia and would be very useful to rationalise .
2. NICE in 2015 indicated a glucose tolerance test at 24-28 weeks. Should the optimum be at 26 weeks?
3. The risk of death from shoulder dystocia was not discussed and is not included in the current RCOG shoulder dystocia patient information leaflet (RCOG 2013).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance on the optimal timing of glucose tolerance testing
Wider context from the report “Although shoulder dystocia is a medical emergency for which staff are trained, it was the elements of the mother’s antenatal care which gave rise to concerns notwithstanding the obvious impact of the pandemic.
The Trust carried out and acted on a full review. However, there are concerns of wider significance: -
1. There is no national guidance for the management of large babies in pregnancy, unless diabetes is present, so it may not be possible to produce a safety recommendation to advise mothers with a suspected large baby.
a) should counselling/management be based on 'macrosomia' (i.e. weight estimated >4500g for diabetes and >5000g for non-diabetic) or alternatively should it now be applied to all babies estimated to be >90th centile by scan >34 weeks?
b) in counselling women about risk of shoulder dystocia in LGA, should this include formal mention of the rare risk of foetal death and if women are to be fully informed should this be balanced by the rare risk of maternal death with an elective Caesarean section (the only other mode of delivery to be considered)?
c) in fact, point b is highly relevant to counselling ALL women about the risks associated with shoulder dystocia and would be very useful to rationalise.
2. NICE in 2015 indicated a glucose tolerance test at 24-28 weeks. Should the optimum be at 26 weeks?
3. The risk of death from shoulder dystocia was not discussed and is not included in the current RCOG shoulder dystocia patient information leaflet (RCOG 2013).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 include the risk of death from shoulder dystocia in patient information
Wider context from the report “Although shoulder dystocia is a medical emergency for which staff are trained, it was the elements of the mother’s antenatal care which gave rise to concerns notwithstanding the obvious impact of the pandemic.
The Trust carried out and acted on a full review. However, there are concerns of wider significance: -
1. There is no national guidance for the management of large babies in pregnancy, unless diabetes is present, so it may not be possible to produce a safety recommendation to advise mothers with a suspected large baby.
a) should counselling/management be based on 'macrosomia' (i.e. weight estimated >4500g for diabetes and >5000g for non-diabetic) or alternatively should it now be applied to all babies estimated to be >90th centile by scan >34 weeks?
b) in counselling women about risk of shoulder dystocia in LGA, should this include formal mention of the rare risk of foetal death and if women are to be fully informed should this be balanced by the rare risk of maternal death with an elective Caesarean section (the only other mode of delivery to be considered)?
c) in fact, point b is highly relevant to counselling ALL women about the risks associated with shoulder dystocia and would be very useful to rationalise.
2. NICE in 2015 indicated a glucose tolerance test at 24-28 weeks. Should the optimum be at 26 weeks?
3. The risk of death from shoulder dystocia was not discussed and is not included in the current RCOG shoulder dystocia patient information leaflet (RCOG 2013).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on management and counselling thresholds for large babies in pregnancy
Wider context from the report “Although shoulder dystocia is a medical emergency for which staff are trained, it was the elements of the mother’s antenatal care which gave rise to concerns notwithstanding the obvious impact of the pandemic.
The Trust carried out and acted on a full review. However, there are concerns of wider significance: -
1. There is no national guidance for the management of large babies in pregnancy, unless diabetes is present , so it may not be possible to produce a safety recommendation to advise mothers with a suspected large baby .
a) should counselling/management be based on 'macrosomia' (i.e. weight estimated >4500g for diabetes and >5000g for non-diabetic) or alternatively should it now be applied to all babies estimated to be >90th centile by scan >34 weeks?
b) in counselling women about risk of shoulder dystocia in LGA, should this include formal mention of the rare risk of foetal death and if women are to be fully informed should this be balanced by the rare risk of maternal death with an elective Caesarean section (the only other mode of delivery to be considered)?
c) in fact, point b is highly relevant to counselling ALL women about the risks associated with shoulder dystocia and would be very useful to rationalise.
2. NICE in 2015 indicated a glucose tolerance test at 24-28 weeks. Should the optimum be at 26 weeks?
3. The risk of death from shoulder dystocia was not discussed and is not included in the current RCOG shoulder dystocia patient information leaflet (RCOG 2013).
” 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 Available evidence is insufficient to recommend induction over expectant management for suspected fetal macrosomia without diabetes.
Verbatim wording from the response “The aim of the evidence review was to determine if Induction of Labour for suspected fetal macrosomia at, or after, 35 weeks gestation, has benefits and reduces the risk of adverse outcomes for the mother and the baby, compared to expectant management. The review looked at all women apart from those with treated diabetes (pre-existing or gestational). The review looked at the following outcomes; third/fourth degree tears; shoulder dystocia; perinatal death; hypoxic ischaemic encephalopathy; maternal satisfaction; brachial plexus injury; and, caesarean birth.” Source location 2021-0249-Response-from-Dept-of-Health-and-Social-Care_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There is insufficient evidence to recommend glucose tolerance testing specifically at 26 weeks.
Verbatim wording from the response “Healthcare professionals should offer women with any of the other risk factors for gestational diabetes (outlined in recommendation 1.2.2) a 75-g 2-hour OGTT at 24 to 28 weeks (recommendation 1.2.7). NICE advises that it does not consider that there is sufficient evidence to make a recommendation for OGTT at 26 weeks.” Source location 2021-0249-Response-from-Dept-of-Health-and-Social-Care_Published
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 existing 24-to-28-week testing window provides flexibility for arranging glucose tolerance tests around 26 weeks.
Verbatim wording from the response “I am further advised by NHSEI that in clinical practice, glucose tolerance tests are routinely arranged to be performed at around 26 weeks gestation and that the 24-28 week recommendation allows some flexibility should there be a problem with the woman attending at exactly 26 weeks.” Source location 2021-0249-Response-from-Dept-of-Health-and-Social-Care_Published
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 NICE guidance adequately covers counselling and birth options for women with suspected large babies.
Verbatim wording from the response “1.17.3 Offer women in labour whose babies are suspected to be large for gestational age a choice between continuing labour, including augmented labour, and caesarean section.” Source location 2021-0249-Response-from-Dept-of-Health-and-Social-Care_Published
Open published response
Concerns raised 2 Risk assessment excluding other risk factors unless the mobility threshold is passed View source Lack of completion guidance and term definitions in the risk assessment form View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jonathan Mark Kingsman · 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
Jonathan Mark Kingsman died from a pulmonary thromboembolism caused by deep vein thrombosis after admission to Fulbourn Hospital. The VTE risk assessment considered mobility first and did not consider other risk factors unless that step was passed, while the form provided no guidance or definitions for certain terms. The report raised concern that this process could fail to identify risk in other patients with significant risk factors but no obviously reduced mobility.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Risk assessment excluding other risk factors unless the mobility threshold is passed
Wider context from the report “That the risk assessment requires no consideration of risk factors other than mobility unless ‘Step 1’ is passed regardless of the number of other risk factors which may be present and their severity – Mr Kingsman was not obviously at risk of ‘significantly increased mobility compared to his normal state’ but died as a result of a DVT/VTE nonetheless. It is reasonable to expect that others may be in the same position in the future;
The risk assessment form contains no guidance on its completion and no definition of certain terms.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 completion guidance and term definitions in the risk assessment form
Wider context from the report “That the risk assessment requires no consideration of risk factors other than mobility unless ‘Step 1’ is passed regardless of the number of other risk factors which may be present and their severity – Mr Kingsman was not obviously at risk of ‘significantly increased mobility compared to his normal state’ but died as a result of a DVT/VTE nonetheless. It is reasonable to expect that others may be in the same position in the future;
The risk assessment form contains no guidance on its completion and no definition of certain terms.
” 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 Identify the best route for developing an updated VTE risk assessment tool covering acute psychiatric wards.
Verbatim wording from the response “I am informed by the National Institute for Health Research (NIHR) that it has supported or funded a number of research studies in relation to VTE prevention. This includes studies in relation to the cost-effectiveness of VTE risk assessment tools for hospital inpatients and looking at the risk of VTE in patients admitted to acute psychiatric wards. NHSEI advise that once these studies are complete, it will then be feasible to create an updated tool to encompass patients on acute psychiatry wards, where NICE guidelines recommend that VTE prophylaxis (usually through injections of Low Molecular Weight Heparin) should be given if the risk of VTE exceeds the risks of bleeding. The National Patient Safety Committee will work to identify the best route to take this forward.” Source location 2021-0238-Response-from-Department-of-Health-Social-Care_Published
Open published response
8 Jul 2021 Maria STANCLIFFE-COOK · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Failure to check risk assessments before downgrading a well-known patient’s suicide risk 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
Maria STANCLIFFE-COOK · 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
Maria STANCLIFFE-COOK was found dead on 1 August 2019 after intentionally taking her own life using helium, causing asphyxiation. The principal concern was that her suicide risk was downgraded from high to medium by members of the mental health team who had not previously dealt with her, followed by a brief telephone contact that did not include an assessment or plan to manage her 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 Failure to check risk assessments before downgrading a well-known patient’s suicide risk
Wider context from the report “The trust have themselves admitted the failures reflected in an independent report they commissioned after the death, that report said “we would not expect a patients level of risk to be downgraded from high ... to medium immediately following a suicide attempt ”; In addition I heard evidence in relation to the assessment on the 26th July 2019 when the risk was downgraded from high to medium.
I listened very carefully to the steps that the Trust has taken to make changes following this death and I am pleased that a number of changes have taken place. I raised my concern about the downgrading of risk from high to medium in this case by two members of the team that had no previous dealings with Maria .
Maria was well known to the trust and her own care coordinator said “We were concerned about the ongoing risk of completed suicide given she continued to be in possession of a helium bottle, the risk was not considered to have changed since my first meeting with her when the risk to self was recorded as high”. That was a reference to a multidisciplinary meeting which took place a matter of weeks before her death.
I was told that risk is dynamic and that professionals assess risk at the time and that it can go up and down. I was also told that there are lots of assessments by staff that do not know patients. That said there is a concern that there is a risk of future death - is it right that the risk of a patient, who is well known to the trust, with a care coordinator who knew her well, is downgraded without any check put in place .
” Open source report
2 Jul 2021 Brooke MARTIN · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1 Failure of healthcare information systems to provide providers with access to complete patient records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brooke MARTIN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Brooke Martin was detained under the Mental Health Act at Isla House, where she was found hanging in her room on 11 June 2019 after earlier ligature-related incidents and concerns about observation and risk assessment. She died at Milton Keynes University Hospital. A principal concern was that incompatible NHS record systems prevented healthcare providers from accessing complete patient records, including information from an out-of-area hospital.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of healthcare information systems to provide providers with access to complete patient records
Wider context from the report “During the course of the evidence it was explained to me that it had not been possible to access the notes and records from an out of area hospital because not all the health providers were using “System One”. It is a major concern that the various systems used throughout the NHS are not compatible with each other and it is not always possible for each healthcare provider to access the notes and records of the patient .
This situation should be reviewed to see how access across the NHS can be gained to patient records when required. I was told by one senior clinician that when a patient is referred to his specialist mental health unit it is often the case, that is 9 times out of 10, he does not receive all the information of the patient’s history . This would not be the case if he had direct access to the records.
” 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 receiving provider was given comprehensive referral information, which it considered sufficient to proceed with admission.
Verbatim wording from the response “In preparing this response, my officials made enquiries with NHS England and NHS Improvement and its South East region. I am advised that as part of the referral process, comprehensive information relating to Miss Martin was shared by the Surrey and Borders Partnership NHS Foundation Trust, which Elysium Healthcare considered sufficient to proceed with Miss Martin’s admission. This included care plans, incident log, risk assessment and clinical information. In addition, I am informed that Miss Martin’s referral to Elysium Healthcare was discussed over a number of weeks between Trust and Elysium Healthcare staff, with continuing communication, including the submission of monthly reports, during Miss Martin’s admission to Chadwick Lodge.” Source location 2021-0299-Response-from-Department-of-Health-and-Social-Care_Published
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations