4 Jan 2021 Linda Joan Gillchrest · Prevention of Future Deaths report Surrey
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Concerns raised 3 Failure to restrict purchase of lethal quantities from UK websites View source Failure to restrict online purchase of publications containing detailed instructions to end a human life View source Lack of protection for vulnerable people before online purchases View source
Responses linked to these concerns
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AI-generated summary
Linda Joan Gillchrest · 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
Linda Joan Gillchrest was found dead at home on 19 July 2020 after not being seen for two days. The inquest heard that she had purchased online a publication containing detailed instructions for self-administering a fatal dose and had bought a quantity of a substance in excess of the recommended fatal dose without restriction. The principal concerns were the unrestricted online availability of such publications and lethal quantities of substances, and the lack of protection for vulnerable people before such purchases.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict purchase of lethal quantities from UK websites
Wider context from the report “During the course of the inquest, evidence was heard that in May 2019 Mrs Gillchrest bought an e-book online from the USA, titled ████████ from a website of the same name. The book gave very clear and precise instructions as to how to self-administer a fatal dose of ████████, including the amount required and a timeline to death. In that month, for less than £5:00, pounds, Mrs Gillchrest purchased, on the auction site ‘www.ebay.co.uk’, a quantity of ████████ that was in excess of that recommended in ████████ as being required for a fatal dose. Both purchases were made without any restriction being imposed by the sellers.
• A publication such as ████████, that contains detailed instructions as to how to end a human life, is available to be purchased online without restriction.
• ████████ is available to be purchased in lethal quantities from a UK website for less than £5:00, again without restriction.
• No protection is afforded to vulnerable people prior to them making such purchases.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 restrict online purchase of publications containing detailed instructions to end a human life
Wider context from the report “During the course of the inquest, evidence was heard that in May 2019 Mrs Gillchrest bought an e-book online from the USA, titled ████████ from a website of the same name. The book gave very clear and precise instructions as to how to self-administer a fatal dose of ████████, including the amount required and a timeline to death. In that month, for less than £5:00, pounds, Mrs Gillchrest purchased, on the auction site ‘www.ebay.co.uk’, a quantity of ████████ that was in excess of that recommended in ████████ as being required for a fatal dose. Both purchases were made without any restriction being imposed by the sellers.
• A publication such as ████████, that contains detailed instructions as to how to end a human life, is available to be purchased online without restriction.
• ████████ is available to be purchased in lethal quantities from a UK website for less than £5:00, again without restriction.
• No protection is afforded to vulnerable people prior to them making such purchases.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of protection for vulnerable people before online purchases
Wider context from the report “During the course of the inquest, evidence was heard that in May 2019 Mrs Gillchrest bought an e-book online from the USA, titled ████████ from a website of the same name. The book gave very clear and precise instructions as to how to self-administer a fatal dose of ████████, including the amount required and a timeline to death. In that month, for less than £5:00, pounds, Mrs Gillchrest purchased, on the auction site ‘www.ebay.co.uk’, a quantity of ████████ that was in excess of that recommended in ████████ as being required for a fatal dose. Both purchases were made without any restriction being imposed by the sellers.
• A publication such as ████████, that contains detailed instructions as to how to end a human life, is available to be purchased online without restriction.
• ████████ is available to be purchased in lethal quantities from a UK website for less than £5:00, again without restriction.
• No protection is afforded to vulnerable people prior to them making such purchases.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with government departments to explore further measures addressing this chemical and emerging suicide methods.
Verbatim wording from the response “The concerns that Mrs Gillchrest’s death raises sit within the policy remits of a range of Government departments, including the Department for Digital, Culture, Media and Sports (DCMS) for its work on online harms; and the Home Office (HO) for its work on the sale of reportable substances³. Officials have shared your concerns with those Departments and are working with officials from those and other Government departments to explore what further steps we can take to prevent further tragedies, both for this chemical, and any other emerging methods.” Source location 2021-0002-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invite Home Office officials to brief NHS, public health and suicide prevention partners on chemical-sale safeguards and support for people at risk.
Verbatim wording from the response “In addition to the cross-Government group set up to put in place steps to tackle emerging methods of suicide, officials at the Department of Health and Social Care have also invited HO officials to brief partners in NHSEI, PHE and suicide prevention stakeholders on what HO can do to ensure that sellers of these chemicals are aware of their potential use in suicide, and on what can be done to get specialist support to those who might be at risk.” Source location 2021-0002-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Suicide Prevention Strategy and Cross-Government Suicide Prevention Workplan, including measures to reduce access to suicide methods.
Verbatim wording from the response “We continue to take action to reduce suicide rates through the Suicide Prevention Strategy for England¹ and the first Cross-Government Suicide Prevention Workplan², which sets out an ambitious programme across national and local government and the NHS. The Workplan includes actions to reduce access to the means of suicide, including through harmful online content.” Source location 2021-0002-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Concerns about selling reportable substances fall within the Home Office’s policy remit.
Verbatim wording from the response “The concerns that Mrs Gillchrest’s death raises sit within the policy remits of a range of Government departments, including the Department for Digital, Culture, Media and Sports (DCMS) for its work on online harms; and the Home Office (HO) for its work on the sale of reportable substances³. Officials have shared your concerns with those Departments and are working with officials from those and other Government departments to explore what further steps we can take to prevent further tragedies, both for this chemical, and any other emerging methods.” Source location 2021-0002-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Online-harms concerns fall within the Department for Digital, Culture, Media and Sport’s policy remit.
Verbatim wording from the response “The concerns that Mrs Gillchrest’s death raises sit within the policy remits of a range of Government departments, including the Department for Digital, Culture, Media and Sports (DCMS) for its work on online harms; and the Home Office (HO) for its work on the sale of reportable substances³. Officials have shared your concerns with those Departments and are working with officials from those and other Government departments to explore what further steps we can take to prevent further tragedies, both for this chemical, and any other emerging methods.” Source location 2021-0002-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Open published response
21 Dec 2020 Evadney Dawkins · Prevention of Future Deaths report East London
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Concerns raised 2 Failure to undertake required renal monitoring View source Failure of governance systems to assess cases as Serious Incidents requiring investigation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Evadney Dawkins · 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
Evadney Dawkins, aged 77, fell at home and was admitted to hospital on 22 July 2018. Renal monitoring planned after assessment was not undertaken for four days, when she was found to have a Grade 3 acute kidney injury; she later suffered a cardiac arrest and was pronounced deceased on 23 August 2018. Concerns also included that the Trust’s governance systems did not identify the case as a Serious Incident requiring investigation for two years.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake required renal monitoring
Wider context from the report “1. On 22nd July 2018, Mrs Dawkins was assessed to require renal monitoring, incorporating;
a) Regular blood tests
b) A renal ultrasound
c) Fluid intake/output monitoring
The 3 actions were not undertaken for 4 days , after which, it was discovered that the patient had deteriorated and had sustained a Grade 3 acute kidney injury.
2. The Trust’s governance systems did not assess to a case as a Serious Incident requiring investigation for 2 years.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of governance systems to assess cases as Serious Incidents requiring investigation
Wider context from the report “1. On 22nd July 2018, Mrs Dawkins was assessed to require renal monitoring, incorporating;
a) Regular blood tests
b) A renal ultrasound
c) Fluid intake/output monitoring
The 3 actions were not undertaken for 4 days, after which, it was discovered that the patient had deteriorated and had sustained a Grade 3 acute kidney injury.
2. The Trust’s governance systems did not assess to a case as a Serious Incident requiring investigation for 2 years.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing Trust systems, including multidisciplinary death reviews and medical examiner scrutiny, are considered sufficient to prevent recurrence of missed Serious Incident identification.
Verbatim wording from the response “I understand the Trust has acknowledged the failure to identify Mrs Dawkins death as a Serious Incident but that it considers that it now has systems in place that mean this is unlikely to happen again. For example, the Trust advises that a multi-disciplinary team now considers unexpected deaths to determine whether investigation under the Serious Incident Review process is appropriate. Additionally, the Trust has appointed three Medical Examiners who review every death within the Trust’s services. As you will know, medical examiners have been introduced to the NHS nationally to provide a new level of independent scrutiny of deaths. Furthermore, the Trust has created a new post of Deputy Medical Director with a remit to provide greater assurance on patient safety governance.” Source location 2020-0292-Response-from-Dept.-of-Health-Social-Care-Redacted
Open published response
18 Dec 2020 Master Ruben Bousquet · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Failure to update the WDRP practical guide to address food allergy deaths View source Delays in notifying food allergy fatalities to relevant food-safety oversight functions View source Absence of a national process and register for food allergy deaths View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Master Ruben Bousquet · 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
Master Ruben Bousquet died after consuming popcorn that had become cross-contaminated with milk protein, causing acute anaphylaxis. The report raised concerns about timely sharing and registration of fatal food-allergy incidents, and about whether food businesses should have access to adrenaline auto-injectors.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to update the WDRP practical guide to address food allergy deaths
Wider context from the report “1. Reporting and Registering
The Head of Incidents at the FSA informed the court that the FSA has started work on a reporting platform for allergic reactions, but needs access to information on all fatalities if it is to have effective oversight of food safety. It would welcome improved appropriate sharing of information on fatalities as they are not routinely notified in a timely manner when there is a report of a fatality by the local authority or coroner.
The Team Leader of Environmental Health in Royal Borough of Greenwich gave evidence that in 2019 the national Work Related Deaths Committee accepted a recommendation that the practical guide of the WDRP should be updated to address concerns surrounding food allergy deaths and the HSE is considering an amendment, but it has not yet been possible to take this forward .
The Head of Trading Standards at the Royal London Borough of Greenwich confirmed that there was no national register (the subject of a PFD report from this jurisdiction in November 2019), but stressed that it is not the HSE who investigates these deaths and that a national process was needed that involved the local authorities coroners and FSA.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 notifying food allergy fatalities to relevant food-safety oversight functions
Wider context from the report “1. Reporting and Registering
The Head of Incidents at the FSA informed the court that the FSA has started work on a reporting platform for allergic reactions, but needs access to information on all fatalities if it is to have effective oversight of food safety . It would welcome improved appropriate sharing of information on fatalities as they are not routinely notified in a timely manner when there is a report of a fatality by the local authority or coroner.
The Team Leader of Environmental Health in Royal Borough of Greenwich gave evidence that in 2019 the national Work Related Deaths Committee accepted a recommendation that the practical guide of the WDRP should be updated to address concerns surrounding food allergy deaths and the HSE is considering an amendment, but it has not yet been possible to take this forward.
The Head of Trading Standards at the Royal London Borough of Greenwich confirmed that there was no national register (the subject of a PFD report from this jurisdiction in November 2019), but stressed that it is not the HSE who investigates these deaths and that a national process was needed that involved the local authorities coroners and FSA.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of a national process and register for food allergy deaths
Wider context from the report “1. Reporting and Registering
The Head of Incidents at the FSA informed the court that the FSA has started work on a reporting platform for allergic reactions, but needs access to information on all fatalities if it is to have effective oversight of food safety. It would welcome improved appropriate sharing of information on fatalities as they are not routinely notified in a timely manner when there is a report of a fatality by the local authority or coroner.
The Team Leader of Environmental Health in Royal Borough of Greenwich gave evidence that in 2019 the national Work Related Deaths Committee accepted a recommendation that the practical guide of the WDRP should be updated to address concerns surrounding food allergy deaths and the HSE is considering an amendment, but it has not yet been possible to take this forward.
The Head of Trading Standards at the Royal London Borough of Greenwich confirmed that there was no national register (the subject of a PFD report from this jurisdiction in November 2019), but stressed that it is not the HSE who investigates these deaths and that a national process was needed that involved the local authorities coroners and FSA .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support the Food Standards Agency’s work to increase information on food-related fatalities.
Verbatim wording from the response “We agree that it is essential that we learn from these tragedies. In conjunction with the FSA’s ongoing programme to collect more information on allergic reactions, the Department of Health and Social Care is working to support the FSA to increase information prevalence regarding such fatalities.” Source location 2020-0298-Response-from-Dept-for-Health-and-Social-Care-Redacted
Open published response
17 Dec 2020 Philip Taylor · Prevention of Future Deaths report Manchester South
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Concerns raised 6 Failure to recognise dehydration risk View source Limited care-home staff ability to recognise and respond to escalating dehydration risk View source National pathfinder tool failing to clearly direct immediate expedited hospital transfer for sepsis View source Delays and omissions in recording GP visit observations View source Lack of national guidance for care-home staff on recognising, responding to and escalating dehydration risk View source Failure to ascertain temperature during care-home GP assessments View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Philip Taylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Philip Taylor, who had Lewy Body Dementia and lived in a residential care home, became severely dehydrated during a chest infection and died in hospital on 6 January 2020 after developing an acute kidney injury. Concerns included failure to recognise and respond to dehydration, delayed ambulance transfer and hospital assessment, inadequate monitoring, and limited national guidance for care home staff and paramedics.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise dehydration risk
Wider context from the report “1. Mr Taylor was seen by a GP the day before he died. His risk of dehydration was not recognised. The precise observations of the GP were difficult to ascertain at the inquest for a number of reasons.
• The inquest was told that the GP had been called as the care home had concerns about Mr Taylor. However, the GP did not ascertain his temperature because the inquest was told that he did not routinely carry or use a thermometer when he saw patients in a care home. The explanation provided to the inquest was that as a GP he did was not equipped with medical gadgets in the way for example NWAS staff were.
• The notes relating to the visit had not been written up until the next day and the GP could not recall all of any observations. It was unclear why that had occurred.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 care-home staff ability to recognise and respond to escalating dehydration risk
Wider context from the report “3. The staff in the care home were not medically qualified. The inquest heard that their ability to recognise and respond to an escalating risk of dehydration was limited . There was no national guidance to assist care home staff in understanding how to recognise; respond and escalate the risk of dehydration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation National pathfinder tool failing to clearly direct immediate expedited hospital transfer for sepsis
Wider context from the report “2. The paramedic attending was a newly qualified paramedic and as a result was using the national pathfinder tool. Mr Taylor was scoring for sepsis on the NWAS observations. However, the crew took well over an hour to leave the care home . The inquest heard that newly qualified paramedics relied on the national pathfinder tool which did not make it clear the need for an immediate expedited transfer to hospital in such circumstances . More experienced paramedics used the Manchester triage tool which was far more explicit. The inquest was told that NWAS had recognised the issue with the national tool and were adjusting their practices to avoid the risk. However, it was not clear if other Ambulance Trusts had made similar adjustments for newly qualified paramedics.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 and omissions in recording GP visit observations
Wider context from the report “1. Mr Taylor was seen by a GP the day before he died. His risk of dehydration was not recognised. The precise observations of the GP were difficult to ascertain at the inquest for a number of reasons.
• The inquest was told that the GP had been called as the care home had concerns about Mr Taylor. However, the GP did not ascertain his temperature because the inquest was told that he did not routinely carry or use a thermometer when he saw patients in a care home. The explanation provided to the inquest was that as a GP he did was not equipped with medical gadgets in the way for example NWAS staff were.
• The notes relating to the visit had not been written up until the next day and the GP could not recall all of any observations . It was unclear why that had occurred.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 care-home staff on recognising, responding to and escalating dehydration risk
Wider context from the report “3. The staff in the care home were not medically qualified. The inquest heard that their ability to recognise and respond to an escalating risk of dehydration was limited. There was no national guidance to assist care home staff in understanding how to recognise; respond and escalate the risk of dehydration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 ascertain temperature during care-home GP assessments
Wider context from the report “1. Mr Taylor was seen by a GP the day before he died. His risk of dehydration was not recognised. The precise observations of the GP were difficult to ascertain at the inquest for a number of reasons.
• The inquest was told that the GP had been called as the care home had concerns about Mr Taylor. However, the GP did not ascertain his temperature because the inquest was told that he did not routinely carry or use a thermometer when he saw patients in a care home . The explanation provided to the inquest was that as a GP he did was not equipped with medical gadgets in the way for example NWAS staff were.
• The notes relating to the visit had not been written up until the next day and the GP could not recall all of any observations. It was unclear why that had occurred.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The choice of clinical triage tool remains the responsibility of individual ambulance services rather than being mandated nationally.
Verbatim wording from the response “I am advised by the North West Ambulance Service (NWAS) that Pathfinder is a clinical presentation-based, triage tool based on the Manchester Triage System, which is used worldwide by emergency clinicians and by a number of ambulance services in the UK. It may be helpful to clarify that Pathfinder is not mandated for use nationally and it remains a decision for individual ambulance services as to which clinical triage tools they use.” Source location 2020-0289-Response-from-Dept.-of-Health-and-Social-Care-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further national dehydration guidance is not considered necessary because appropriate guidance and best-practice materials already exist.
Verbatim wording from the response “In relation to the national guidance that is available to care home staff on recognising and responding to the risk of dehydration, I am advised that in its response to you, the CQC has provided a detailed explanation of the guidance and best practice materials that are available. I will not repeat the detail here. However, you may wish to note that Departmental officials have made enquiries with NICE, which has confirmed that appropriate guidance is available, issued by NICE itself and others.” Source location 2020-0289-Response-from-Dept.-of-Health-and-Social-Care-Redacted
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No Pathfinder changes are considered necessary because the tool remains a safe and effective assessment and triage tool.
Verbatim wording from the response “I am assured by the NWAS that having considered the concerns you have raised carefully, it believes that changes are not required as a result of this incident and that Pathfinder remains a safe and effective assessment triage tool.” Source location 2020-0289-Response-from-Dept.-of-Health-and-Social-Care-Redacted
Open published response
15 Dec 2020 Eddie Coffey · Prevention of Future Deaths report Hertfordshire
View report summary
Concerns raised 4 Failure to establish that training prevents recurrence of the same situation View source Use of wrong guidelines for foetal heart rate monitoring in labour View source Failure in basic medical care for foetal heart rate monitoring and management during labour View source Failure of serious incident investigation to determine directly responsible factors View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Eddie Coffey · 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
Eddie Coffey was born at Lister Hospital in a poor state, with a low heart rate and symptoms of hypoxia, and required resuscitation before transfer to neonatal intensive care. He died at Luton & Dunstable Hospital from perinatal asphyxia. Inquest evidence identified gross failures in monitoring and managing the foetal heart rate during labour, and raised concerns about whether the same situation could recur and whether other maternity units were following incorrect guidelines.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to establish that training prevents recurrence of the same situation
Wider context from the report “(4) It was not clear from the inquest that, despite training implemented by the Trust since the death, that the same situation would not arise again .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 wrong guidelines for foetal heart rate monitoring in labour
Wider context from the report “(5) The Evidence was given at the inquest by an independent Consultant Obstetrician that 100 maternity units in the country are following the wrong guidelines in relation to managing foetal heart rate monitoring in labour .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 in basic medical care for foetal heart rate monitoring and management during labour
Wider context from the report “(2) Evidence was given at the inquest by a Consultant Obstetrician from Lister Hospital that there was a gross failure in the basic medical care provided in the monitoring and management of the foetal heart rate during the labour, and that but for that failure Eddie Coffey might have survived.
(3) Evidence was given at the inquest by an independent Consultant Obstetrician that there was a gross failure in the basic medical care provided in the monitoring and management of the foetal heart rate during the labour, and that but for that failure Eddie Coffey would more than likely have survived.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of serious incident investigation to determine directly responsible factors
Wider context from the report “(1) The Serious Incident Report prepared on behalf of East and North Hertfordshire NHS Trust concluded that the Investigation was unable to determine the factors that were directly responsible for the death of baby Eddie Coffey . This conclusion was directly contradicted by evidence at the inquest .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Award £9.4 million to support maternity safety pilots using investigation and research learning, training and expert guidance to improve childbirth practice.
Verbatim wording from the response “In addition, £9.4million was awarded in the 2020 Spending Review to support maternity safety pilots that will include fresh learning from recent investigations and academic research to be used to improve clinical practice during childbirth, and cutting-edge training and expert guidance to improve practice and avoid harm to babies.” Source location 2020-0287-Response-from-Dept.-for-Health-and-Social-Care-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Bring the coroner’s report to the attention of the Healthcare Safety Investigation Branch.
Verbatim wording from the response “Finally, my officials have brought your report to the attention of the Healthcare Safety Investigation Branch (HSIB). HSIB is a key part of our commitment to improve patient safety and the culture of learning in the NHS. The HSIB conduct independent maternity investigations that meet the Each Baby Counts criteria and a defined criteria for maternal deaths so that the NHS learns quickly from what went wrong and uses this to prevent future tragedies. Where HSIB identifies systemic risks, it can consider making national recommendations for system change.” Source location 2020-0287-Response-from-Dept.-for-Health-and-Social-Care-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Trusts are responsible for implementing the Saving Babies’ Lives Care Bundle and appointing fetal-monitoring leads.
Verbatim wording from the response “In relation to monitoring fetal wellbeing, NHS Trusts are being asked to implement the saving babies lives bundle. Element 4 of the Saving Babies Lives Care Bundle Version 2 (SBLCBv2)⁶ already states there needs to be one lead with the responsibility of improving the standard of fetal monitoring. NHS Trusts are now being asked to ensure that a second lead is identified so that every unit has a lead midwife and a lead obstetrician in place to lead best practice, learning and support. This will include regular training sessions, review of cases and ensuring compliance with the SBLCBv2 and national guidelines.” Source location 2020-0287-Response-from-Dept.-for-Health-and-Social-Care-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS providers and local health partners are responsible for implementing the Patient Safety Incident Response Framework and supporting standards.
Verbatim wording from the response “NHSEI is currently working with early adopters to pilot the new Framework. The learning from this pilot will be used to inform the final version of the Framework. Until this is finalized, NHS providers and their local health partners should review the introductory framework and Patient Safety Incident Investigation standards⁴ and begin to consider what they will need to do to support their implementation.” Source location 2020-0287-Response-from-Dept.-for-Health-and-Social-Care-Redacted
Open published response
Concerns raised 1 Lack of immediate, prominent medication warnings about increased suicidal thinking risk in young adults View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samuel David Morgan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Samuel David Morgan died at home on 16 January 2020 as a consequence of self-suspension. His risk of taking his own life had not been identified, and a review assessment was not set when citalopram was prescribed. Concerns included a change in mood after starting the medication and whether clearer warnings about the risk of suicidal thinking in young adults would better capture patients’ attention.
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 immediate, prominent medication warnings about increased suicidal thinking risk in young adults
Wider context from the report “Every medicine pack includes a patient information leaflet (PIL), which provides information on using the medicine safely and allows patients to read at their leisure. However, it has been suggested that the “Black Box Warning” (as developed by the Food and Drug Administration in the USA) would have a more immediate impact and capture some patient’s attention highlighting any risks . The simple and clear message in this specific case would be that there is an increased risk of suicidal thinking in young adults. The benefits of such simple and direct messaging extends to all prescribed medicines and associated major risks.
” 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 has found no evidence that United States-style black-box warnings communicate medicine risks more effectively than UK patient information leaflets.
Verbatim wording from the response “My officials have liaised with the Medicines and Healthcare products Regulatory Agency (MHRA) which I know has considered carefully your comments about the presentation of risks associated with citalopram and other selective serotonin reuptake inhibitor (SSRI) medicines on Patient Information Leaflets, and by extension the presentation of major risks associated with all prescribed medicines.” Source location 2020-0276-Response-from-Dept.-of-Health-and-Social-Care-Redacted
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, product information, BNF and MHRA guidance is considered adequate to inform SSRI risk discussions and monitoring, particularly when treatment begins.
Verbatim wording from the response “Clinicians are expected to take account of NICE guidelines, product information and advice in the BNF when discussing treatment options with a patient, ensuring that patients are aware of known risks associated with medicines so that properly informed decisions are taken. The risk of suicidal behaviour associated with SSRIs, particularly in young people aged up to 25 years, has been highlighted to healthcare professionals via MHRA Drug Safety Updates, as well as in published guidance by the MHRA². The GP handbook, the British National Formulary (BNF) also highlights these risks and the importance of monitoring particularly at the start of treatment.” Source location 2020-0276-Response-from-Dept.-of-Health-and-Social-Care-Redacted
Open published response
8 Dec 2020 Ann Doris Stillwell · Prevention of Future Deaths report East London
View report summary
Concerns raised 1 Failure to authorise 1:1 care for a person at high risk of falls View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ann Doris Stillwell · 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
Ann Doris Stillwell, who was at high risk of falls, sustained a left-sided neck of femur fracture after a fall in her care home on 3 July 2020 and died from complications of her injuries on 5 July 2020. The principal concern was that 1:1 care was not authorised despite the identified risk, and the report states that this would have been the only way to mitigate the particular risk she presented to herself.
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 authorise 1:1 care for a person at high risk of falls
Wider context from the report “1. Mrs Stillwell was at high risk of falls during the entirety of the period of 25th May 2020 until the 3rd July 2020. During that period the Commissioner for her care did not authorise 1:1 care. 1:1 care would have been the only way in which the particular risk presented by Mrs Stillwell to herself could have been mitigated.
” 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 No change to national continuing healthcare policy is considered necessary in response to the concerns.
Verbatim wording from the response “The Department has considered the concerns raised in your report and in this instance, we do not consider that a change in national policy is required. However, Departmental officials will work with NHS England, which is responsible for providing assurance on the actions of CCGs, to consider the specific circumstances of this case and whether further regional monitoring may be required.” Source location 2021-0091-Response-from-Dept-of-Health-and-Social-Care-Redacted
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 Clinical commissioning groups are responsible for commissioning one-to-one care within their local areas.
Verbatim wording from the response “CCGs are responsible for the commissioning of 1:1 care within their local areas. I understand that Barking and Dagenham Havering, and Redbridge CCGs, have provided a joint response which sets out the actions taken to learn from the findings presented, following Mrs Stillwell’s death.” Source location 2021-0091-Response-from-Dept-of-Health-and-Social-Care-Redacted
Open published response
2 Dec 2020 Ivan Merryfield O’Neill · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Limited physiological reserve increasing risk of rapid loss of consciousness following bleeding View source Restlessness during dialysis increasing risk of needle dislodgement View source Failure of dialysis equipment alarms to promptly alert staff to bleeding View source Failure to position dialysis patients within a clear line of sight from the nurses station 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
Ivan Merryfield O’Neill · 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
Ivan Merryfield O’Neill bled to death during a dialysis appointment after a venous needle became dislodged from his arteriovenous fistula. Concerns included his restlessness and frailty, his position outside a clear line of sight from the nurses’ station, and an alarm that did not promptly alert staff to the bleed.
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 Limited physiological reserve increasing risk of rapid loss of consciousness following bleeding
Wider context from the report “2. Mr O’Neill was a frail patient with little reserve and would be more likely to swiftly lose consciousness following a bleed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Restlessness during dialysis increasing risk of needle dislodgement
Wider context from the report “1. Mr O’Neill was known to be a restless patient during a dialysis session . This factor must have increased the risk of needle dislodgement .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 dialysis equipment alarms to promptly alert staff to bleeding
Wider context from the report “4. The automatic alarm triggered by the dialysis equipment was insufficiently sensitive to promptly alert staff to a bleed until between 200 – 2000 mls of blood had already been lost .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to position dialysis patients within a clear line of sight from the nurses station
Wider context from the report “3. Mr O’Neill was placed in a position which was outside of a clear line of sight from the nurses station .
” Open source report
1 Dec 2020 Violet Leona Jackman · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Insufficient Health Visitor capacity to support new parents and young children View source Failure to elicit parents’ descriptions of sleeping arrangements View source Lack of national clarity about protecting Health Visitor services from redeployment View source Failure to ensure that shared-care parents understand safe sleeping guidance 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
Violet Leona Jackman · 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
Violet Leona Jackman was a baby who was found unresponsive on 17 May 2020 in a bed at her home; the Moses basket in which she had been sleeping had tipped over. Concerns included safe-sleeping advice being given only to her mother despite shared care, a lack of detailed checking of sleeping arrangements, and reduced Health Visitor availability during the first wave of Covid-19.
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 Health Visitor capacity to support new parents and young children
Wider context from the report “3. The inquest was told that during the first wave of Covid 19, Health Visitors nationally were redeployed into other services. In the area served by this team that meant a 20% reduction decrease in available Health Visitors and stretched services to support new parents significantly . In Trafford, a decision had since been taken that the situation should not continue even in a second wave, given the stretch this put on Health Visitor services and their ability to support parents and young children. However, it was unclear if nationally a similar approach was being taken, or if Health Visitor services were being reduced to support other front line services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 elicit parents’ descriptions of sleeping arrangements
Wider context from the report “2. The guidance was given as a series of points. The inquest heard that as a general rule, health visitors do not ask parents to explain in a free text style the sleeping arrangements . It is likely if they had asked for such a description, then they would have been made aware of how the guidance had been interpreted and the sleeping arrangement in place. If they had then the inquest was told that her parents would have been told that the location of the basket was inconsistent with safe sleeping.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 clarity about protecting Health Visitor services from redeployment
Wider context from the report “3. The inquest was told that during the first wave of Covid 19, Health Visitors nationally were redeployed into other services. In the area served by this team that meant a 20% reduction decrease in available Health Visitors and stretched services to support new parents significantly. In Trafford, a decision had since been taken that the situation should not continue even in a second wave, given the stretch this put on Health Visitor services and their ability to support parents and young children. However, it was unclear if nationally a similar approach was being taken , or if Health Visitor services were being reduced to support other front line services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that shared-care parents understand safe sleeping guidance
Wider context from the report “1. Safe sleeping advice was given to her mother, although it was clear that care would be shared. There was no clear way of ensuring that both parents understood the guidance given or following up that the advice had been shared in detail.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue providing health visitors and their teams with evidence and advice to support both parents’ engagement in infant care.
Verbatim wording from the response “Fathers have an equally vital role during pregnancy and throughout their child’s life and the first few weeks and months are critical. We will continue to provide health visitors and their teams with evidence and advice on how to ensure both fathers and mothers are supported to adapt to parenthood and engaged in the care of their child.” Source location 2020-0263-Response-from-Department-of-Health-and-Social-Care-Redacted
Open published response
26 Nov 2020 Lee Elliott · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 2 Lack of safeguards for internet purchase of toxic substances View source Online promotion and encouragement of suicide methods View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lee Elliott · 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 Elliott had experienced mental health difficulties and was found deceased in his bedroom on 6 February 2020. The inquest recorded that he had purchased a chemical from an internet supplier and ingested it, causing his death. The principal concerns were the online promotion of the substance as a suicide method and its easy, inexpensive purchase without safeguards.
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 safeguards for internet purchase of toxic substances
Wider context from the report “(2) ████████ [and other toxic substances] are easily and cheaply obtainable in small amounts by internet purchase with no safeguards .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Online promotion and encouragement of suicide methods
Wider context from the report “(1) ████████ is being advocated by several websites easily found on the internet as a reliable and pain free way of taking one’s life . Often advice is given on the use of prescription medications to take to minimise any nausea caused when a solution of this substance is drunk. Links can be found to discussion groups which may encourage vulnerable and sick people to attempt to take their lives .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Cross-Government Suicide Prevention Workplan, including measures to reduce access to suicide means through harmful online content.
Verbatim wording from the response “We continue to take action to reduce suicide rates through the Suicide Prevention Strategy for England¹ and the first Cross-Government Suicide Prevention Workplan², which sets out an ambitious programme across national and local government and the NHS. The Workplan includes actions to reduce access to the means of suicide, including through harmful online content.” Source location 2020-0265-Response-from-Dept-of-Health-and-Social-Care-Redacted.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 Work with other Government departments to explore further steps preventing deaths involving this chemical and emerging suicide methods.
Verbatim wording from the response “The concerns that Mr Elliott’s death raises sit within the policy remits of a range of Government departments, including the Department for Digital, Culture, Media and Sports (DCMS) for its work on online harms; and the Home Office (HO) for its work on the sale of reportable substances³. Officials have shared your concerns with those Departments and are working with officials from those and other Government departments to explore what further steps we can take to prevent further tragedies, both for this chemical, and any other emerging methods.” Source location 2020-0265-Response-from-Dept-of-Health-and-Social-Care-Redacted.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 Invite Home Office officials to brief NHS, public health and suicide prevention partners on chemical-sale safeguards and support for people at risk.
Verbatim wording from the response “In addition to the cross-Government group set up to put in place steps to tackle emerging methods of suicide, officials at the Department of Health and Social Care have also invited HO officials to brief partners in NHSEI, PHE and suicide prevention stakeholders on what HO can do to ensure that sellers of these chemicals are aware of their potential use in suicide, and what can be done to get specialist support to those who might be at risk.” Source location 2020-0265-Response-from-Dept-of-Health-and-Social-Care-Redacted.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 Operate a cross-Government group to develop measures addressing emerging suicide methods.
Verbatim wording from the response “We continue to take action to reduce suicide rates through the Suicide Prevention Strategy for England¹ and the first Cross-Government Suicide Prevention Workplan², which sets out an ambitious programme across national and local government and the NHS. The Workplan includes actions to reduce access to the means of suicide, including through harmful online content.” Source location 2020-0265-Response-from-Dept-of-Health-and-Social-Care-Redacted.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 Ask the Law Commission to examine how criminal law addresses encouragement, assistance and incitement of self-harm.
Verbatim wording from the response “On 15 December 2020, DCMS published its response to the White Paper consultation, setting out how the proposed legal duty of care on online companies will work in practice and gives them new responsibilities towards their users. DCMS also announced that the Government has asked the Law Commission to examine how criminal law will address the encouragement, assistance and incitement of self-harm.” Source location 2020-0265-Response-from-Dept-of-Health-and-Social-Care-Redacted.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 Controls on the sale of reportable substances fall within the Home Office’s policy remit.
Verbatim wording from the response “The concerns that Mr Elliott’s death raises sit within the policy remits of a range of Government departments, including the Department for Digital, Culture, Media and Sports (DCMS) for its work on online harms; and the Home Office (HO) for its work on the sale of reportable substances³. Officials have shared your concerns with those Departments and are working with officials from those and other Government departments to explore what further steps we can take to prevent further tragedies, both for this chemical, and any other emerging methods.” Source location 2020-0265-Response-from-Dept-of-Health-and-Social-Care-Redacted.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 Online-harm concerns fall within the Department for Digital, Culture, Media and Sport’s policy remit.
Verbatim wording from the response “The concerns that Mr Elliott’s death raises sit within the policy remits of a range of Government departments, including the Department for Digital, Culture, Media and Sports (DCMS) for its work on online harms; and the Home Office (HO) for its work on the sale of reportable substances³. Officials have shared your concerns with those Departments and are working with officials from those and other Government departments to explore what further steps we can take to prevent further tragedies, both for this chemical, and any other emerging methods.” Source location 2020-0265-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Open published response
26 Nov 2020 Neville Bardoliwalla · Prevention of Future Deaths report North London
View report summary
Concerns raised 1 Lack of a process for collecting and disposing of prescribed controlled medication 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
Neville Bardoliwalla · 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
Neville Bardoliwalla was found at home on 10 March 2020 after hanging himself from two screws in a door frame. Evidence was heard that he had accumulated prescribed controlled medication and that there was no process for collecting and disposing of it.
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 for collecting and disposing of prescribed controlled medication
Wider context from the report “1. Evidence was heard regarding the fact that prescribed controlled medication had been accumulated by Mr Bardoliwalla and that there was no process for collecting and disposing of this medication .
” Open source report
24 Nov 2020 Mrs Ann Patricia Ellen Schuetz · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 2 Failure of primary and secondary care electronic patient systems to share allergy information View source Lack of allergy-recording functionality in the CAMIS system 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 Ann Patricia Ellen Schuetz · 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 Ann Patricia Ellen Schuetz died at Northampton General Hospital on 26 June 2018 following an allergic reaction to Ramipril. The report identifies concerns that her known allergy was not recorded across relevant electronic systems, which allowed Ramipril to be restarted and continued to be prescribed.
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 primary and secondary care electronic patient systems to share allergy information
Wider context from the report “In the present case, the allergy was not recorded in the appropriate places in the relevant electronic systems. A contributing factor was that that primary and secondary care have a number of different electronic systems in place to manage patient medical information including:-
1. Symphony – Emergency Department system
2. EDN – Electronic Discharge Notification system
3. ePMA – Electronic prescribing system
4. SystemOne – Electronic GP documentation system
5. CAMIS – Overview system which holds such details as ID and all attendances including outpatient
One of the root causes according to the Trust’s Investigation report was “the fact that the electronic patient systems used in primary and secondary care did not have the ability to share information and therefore the updated allergy information was required to be inputted manually into each system ….”
The Trust is continuing to explore the feasibility of having regional central medical records but it is not known if any other Trusts are doing the same.
The Investigation report also states that “The CAMIS system currently does not have anywhere to record a patient’s allergies. If a change is to be made to the CAMIS system, this would need to be changed nationally”.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of allergy-recording functionality in the CAMIS system
Wider context from the report “In the present case, the allergy was not recorded in the appropriate places in the relevant electronic systems. A contributing factor was that that primary and secondary care have a number of different electronic systems in place to manage patient medical information including:-
1. Symphony – Emergency Department system
2. EDN – Electronic Discharge Notification system
3. ePMA – Electronic prescribing system
4. SystemOne – Electronic GP documentation system
5. CAMIS – Overview system which holds such details as ID and all attendances including outpatient
One of the root causes according to the Trust’s Investigation report was “the fact that the electronic patient systems used in primary and secondary care did not have the ability to share information and therefore the updated allergy information was required to be inputted manually into each system….”
The Trust is continuing to explore the feasibility of having regional central medical records but it is not known if any other Trusts are doing the same.
The Investigation report also states that “The CAMIS system currently does not have anywhere to record a patient’s allergies . If a change is to be made to the CAMIS system, this would need to be changed nationally”.
” Open source report
Concerns raised 2 Unrestricted availability of a lethal substance as a meat preservative View source Active promotion of a particular method of death by suicide View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jason THOMPSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jason THOMPSON, a 49-year-old man, collapsed at home after taking a quantity of a substance and died shortly afterwards in Darlington Memorial Hospital on 8 February 2020. The concerns included the ready availability of a lethal substance, including through a popular online platform, and material allegedly describing its use to commit suicide and potentially promoting that method.
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 Unrestricted availability of a lethal substance as a meat preservative
Wider context from the report “‘████████ is used to preserve and cure meat, to which it imparts a pink-red colour. The minimum lethal dose is ████████. ████████ can be readily bought via the ████████. For example, it is possibly to buy up to ████████ for a few pounds on ████████, without restriction. A chapter from Salts’, available ████████, describes the use of ████████ to commit suicide and compares it with ████████ and ████████.”
(1) ████████ may be actively promoting a particular method of death by suicide and hence breaking the criminal law by assisting suicide.
(2) That such a lethal substance ████████ should be so freely available on a popular ████████ ████████, sold by a company (████████) under the guise of being a meat preservative.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Active promotion of a particular method of death by suicide
Wider context from the report “‘████████ is used to preserve and cure meat, to which it imparts a pink-red colour. The minimum lethal dose is ████████. ████████ can be readily bought via the ████████. For example, it is possibly to buy up to ████████ for a few pounds on ████████, without restriction. A chapter from Salts’, available ████████, describes the use of ████████ to commit suicide and compares it with ████████ and ████████.”
(1) ████████ may be actively promoting a particular method of death by suicide and hence breaking the criminal law by assisting suicide.
(2) That such a lethal substance ████████ should be so freely available on a popular ████████ ████████, sold by a company (████████) under the guise of being a meat preservative.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Investigate available data on suicides using this method and identify steps to prevent further deaths from this and emerging methods.
Verbatim wording from the response “I am advised that suicide prevention policy leads in the health system, at the Department of Health and Social Care, Public Health England (PHE), and NHS England and NHS Improvement (NHSEI), are alert to the risk posed by websites promoting suicide methods, and their direction on the use of certain chemicals in completing suicide, including the substance taken by Mr Thompson. These organisations, along with key stakeholders and academics, are looking at what data is available on suicides by this method and at what steps we can take to stop further loss of life by this method.” Source location 2020-0246-Response-from-Dept.-of-Health-Social-Care-Redacted.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 Continue implementing suicide-prevention strategy and cross-government workplan measures to reduce access to suicide methods and harmful online content.
Verbatim wording from the response “We continue to take action to reduce suicide rates through the Suicide Prevention Strategy for England¹ and the first Cross-Government Suicide Prevention Workplan², which sets out an ambitious programme across national and local government and the NHS. The Workplan include actions to reduce access to the means of suicide, including through harmful online content.” Source location 2020-0246-Response-from-Dept.-of-Health-Social-Care-Redacted.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 Invite Home Office officials to brief NHS, public health and suicide-prevention partners on chemical-seller safeguards and specialist support for people at risk.
Verbatim wording from the response “In addition to the cross-Government group set up to put in place steps to tackle emerging methods of suicide, officials at the Department of Health and Social Care have also invited HO officials to brief partners in NHSEI, PHE and suicide prevention stakeholders on what HO can do to ensure that sellers of these chemicals are aware of their potential use in suicide, and on what can be done to get specialist support to those who might be at risk.” Source location 2020-0246-Response-from-Dept.-of-Health-Social-Care-Redacted.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 Work with other government departments to explore further measures addressing this chemical and emerging suicide methods.
Verbatim wording from the response “The concerns that Mr Thompson’s death raises sit within the policy remits of a range of Government departments, including the Department for Digital, Culture, Media and Sports (DCMS) for its work on online harms; and the Home Office (HO) for its work on the sale of reportable substances³. Officials have shared your concerns with those Departments and are working with officials from those and other Government departments to explore what further steps we can take to prevent further tragedies, both for this chemical, and any other emerging methods.” Source location 2020-0246-Response-from-Dept.-of-Health-Social-Care-Redacted.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 Online-harm concerns are assigned to DCMS, while concerns about sale of reportable substances are assigned to the Home Office.
Verbatim wording from the response “The concerns that Mr Thompson’s death raises sit within the policy remits of a range of Government departments, including the Department for Digital, Culture, Media and Sports (DCMS) for its work on online harms; and the Home Office (HO) for its work on the sale of reportable substances³. Officials have shared your concerns with those Departments and are working with officials from those and other Government departments to explore what further steps we can take to prevent further tragedies, both for this chemical, and any other emerging methods.” Source location 2020-0246-Response-from-Dept.-of-Health-Social-Care-Redacted.pdf
Open published response
18 Nov 2020 Alfie Gildea · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 22 Limited police recognition and use of Claire's Law in domestic abuse cases View source Unqualified staff making key MARAT decisions View source Inconsistent definitions and thresholds for serious or serial domestic abuse perpetrators View source Lack of police understanding of policy and required actions for serial or serious domestic abuse perpetrators View source Poor information sharing and joint risk recognition across statutory agencies View source Limited police training and capability to identify coercive and controlling behaviour View source Insufficient health visitor capacity for safeguarding and interagency work View source Failure to ensure serial and serious domestic abuse perpetrator information is recorded and accessible View source Reduced specialist support and oversight for low and medium risk domestic abuse cases View source Failure to share complete relevant information between police and CPS View source Failure of CPS decision makers to follow guidance and document prosecution assessments View source Limited health visitor understanding of coercive and controlling behaviour View source Failure to provide a clear and effective system for notifying alleged victims of DVPNs and DVPOs View source Failure to share perpetrator risk information with alleged victims View source Failure to place domestic abuse suspects on protective bail conditions during further investigation View source Failure to provide safe opportunities for domestic abuse disclosure View source Failure to pursue further enquiries supporting victimless domestic abuse prosecutions View source Failure to routinely document police and CPS case discussions View source Failure to use the MARAC framework when appropriate View source Limited police training in domestic abuse risk evaluation and scoring View source Insufficient resourcing of the MARAT frontline service View source Failure to conduct required health visiting conversations face to face View source See 19 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alfie Gildea · 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
Alfie Gildea sustained catastrophic injuries consistent with being shaken with force while in his father's care on 12 September 2018 and died from his injuries on 14 September 2018. The report identifies concerns about failures by police, children's services, health visiting services and the CPS to recognise, assess, share and act on domestic abuse risks, including coercive and controlling behaviour.
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 Limited police recognition and use of Claire's Law in domestic abuse cases
Wider context from the report “7. Recognition of when and how Claire's Law should be used and the understanding of its importance in DA cases was limited amongst the officers giving evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unqualified staff making key MARAT decisions
Wider context from the report “15. The inquest was told that at the time the MARAT – front line service – was significantly under resourced. This was confirmed via an OFSTED inspection shortly after Alfie's death. As a result staff were stretched and staff who were not qualified social workers were making key decisions . Trafford Local Authority have increased resourcing but it was unclear if the lessons learnt by Trafford as a result of Alfie's death had been shared nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistent definitions and thresholds for serious or serial domestic abuse perpetrators
Wider context from the report “2. The inquest was told that the GMP/CPS definitions of a serious/serial domestic abuser perpetrator were different . It was unclear why that was the case. However as a result there are different points at which an offender's background triggers the requirement to treat the suspect as a serial/serious DA perpetrator .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 police understanding of policy and required actions for serial or serious domestic abuse perpetrators
Wider context from the report “4. There was a lack of understanding amongst police witnesses about the GMP policy in relation to serial/serious DA perpetrators and the actions that were required under GMPs policy .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor information sharing and joint risk recognition across statutory agencies
Wider context from the report “12. Information sharing between all of the statutory agencies in particular health; Local Authority and Police was poor . As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator . Opportunities to use the MARAC framework were not taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Limited police training and capability to identify coercive and controlling behaviour
Wider context from the report “5. Evidence at the inquest suggested that the majority of officers had received very limited training in relation to DA and in particular coercive and controlling behaviour . Understanding of how coercive and controlling behaviour in a relationship could be identified was limited .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 health visitor capacity for safeguarding and interagency work
Wider context from the report “14. The inquest was told that Health Visitor numbers were reducing due to national funding arrangements . As a result the service was becoming increasingly stretched which decreased the ability of health visitors to support vulnerable families, identify risk, build relationships or engage with other agencies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 serial and serious domestic abuse perpetrator information is recorded and accessible
Wider context from the report “3. It is unclear where the information that an individual met the criteria for a serial and serious DA Perpetrator should or did sit in GMPs systems . Officers giving evidence did not understand how such information could be accessed or recorded .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Reduced specialist support and oversight for low and medium risk domestic abuse cases
Wider context from the report “9. The inquest heard that since the death of Alfie GMP had restructured and removed the PPIU units. However the inquest heard that as a result the limited specialist support and oversight offered to neighbourhood/response officers had further reduced in low/medium risk DA cases .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to share complete relevant information between police and CPS
Wider context from the report “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed . The file that was submitted omitted key information available to GMP that would have been important to the decision maker . The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 CPS decision makers to follow guidance and document prosecution assessments
Wider context from the report “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim . The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 health visitor understanding of coercive and controlling behaviour
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself . Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a clear and effective system for notifying alleged victims of DVPNs and DVPOs
Wider context from the report “11. The GMP policy on notification of DVPN/DVPOs to alleged victims was not followed . There was no evidence of a clear and effective system of notification on the Trafford Division of GMP .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to share perpetrator risk information with alleged victims
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 place domestic abuse suspects on protective bail conditions during further investigation
Wider context from the report “1. The inquest was told that at the time of the allegation of assault in July 2018 suspects in domestic abuse cases were not placed on bail with conditions, to protect alleged victims, where further investigation was required . Instead they were placed under investigation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 safe opportunities for domestic abuse disclosure
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 pursue further enquiries supporting victimless domestic abuse prosecutions
Wider context from the report “8. The limited training and understanding of GMP officers meant that lines of further enquiry that would allow for a victimless prosecution were not followed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely document police and CPS case discussions
Wider context from the report “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 the MARAC framework when appropriate
Wider context from the report “12. Information sharing between all of the statutory agencies in particular health; Local Authority and Police was poor. As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator. Opportunities to use the MARAC framework were not taken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Limited police training in domestic abuse risk evaluation and scoring
Wider context from the report “6. The inquest was told that the DASH risk assessment is a national tool. However training of GMP officers on understanding how to evaluate risk and score risk was limited .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 resourcing of the MARAT frontline service
Wider context from the report “15. The inquest was told that at the time the MARAT – front line service – was significantly under resourced . This was confirmed via an OFSTED inspection shortly after Alfie's death. As a result staff were stretched and staff who were not qualified social workers were making key decisions. Trafford Local Authority have increased resourcing but it was unclear if the lessons learnt by Trafford as a result of Alfie's death had been shared nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct required health visiting conversations face to face
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face . The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure.
” 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 domestic-abuse guidance for health professionals, including responsibilities for responding to victims and practical guidance on perpetrators.
Verbatim wording from the response “In March 2017, the Department published a resource for health professionals, Responding to domestic abuse[1], an update to a handbook for healthcare professionals published in 2005.” Source location 2020-0242-Response-from-Dept.-of-Health-and-Social-Care-Redacted.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 authorities, not the Department, determine required health visitor numbers according to local needs.
Verbatim wording from the response “Since 2015, local authorities have been responsible for the commissioning of services for children between the ages of 0-5 and it is for local authorities to determine the required numbers of health visitors based upon local needs. All commissioning should be based on a robust Joint Strategic Needs Assessment and supported by local workforce plans. In this financial year, local authorities will receive a £3.279 billion public health grant for their public health duties for all ages[5].” Source location 2020-0242-Response-from-Dept.-of-Health-and-Social-Care-Redacted.pdf
Open published response
12 Nov 2020 Amarbai Bhudia · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Lack of clinical instruction for nursing staff on NG tube management View source Failure to properly escalate concerns regarding NG tube function to clinical staff View source Use of nursing staff without training or experience in NG tube management View source Failure to clearly record instructions on NG tube management 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
Amarbai Bhudia · 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
Amarbai Bhudia was admitted to hospital with abdominal pain and vomiting and was managed for a small intestine obstruction using a naso-gastric tube. The tube was not aspirated, and she collapsed and suffered a cardiac arrest caused by aspiration of gastro-intestinal contents; concerns included unclear instructions, lack of nursing guidance and training, and inadequate escalation of concerns about the tube.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical instruction for nursing staff on NG tube management
Wider context from the report “1. Instructions on the management of the NG tube were provided on a ward round by a consultant, the instructions were not clearly noted by the House Officer accompanying the consultant.
2. Nursing staff had no clinical instruction as to how to manage the NG tube .
3. Nursing staff dealing with the patient were agency staff without training or experience of NG tube management.
4. Concerns regarding the NG tube function were not properly escalated to clinical staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to properly escalate concerns regarding NG tube function to clinical staff
Wider context from the report “1. Instructions on the management of the NG tube were provided on a ward round by a consultant, the instructions were not clearly noted by the House Officer accompanying the consultant.
2. Nursing staff had no clinical instruction as to how to manage the NG tube.
3. Nursing staff dealing with the patient were agency staff without training or experience of NG tube management.
4. Concerns regarding the NG tube function were not properly escalated to clinical staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Use of nursing staff without training or experience in NG tube management
Wider context from the report “1. Instructions on the management of the NG tube were provided on a ward round by a consultant, the instructions were not clearly noted by the House Officer accompanying the consultant.
2. Nursing staff had no clinical instruction as to how to manage the NG tube.
3. Nursing staff dealing with the patient were agency staff without training or experience of NG tube management .
4. Concerns regarding the NG tube function were not properly escalated to clinical staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly record instructions on NG tube management
Wider context from the report “1. Instructions on the management of the NG tube were provided on a ward round by a consultant, the instructions were not clearly noted by the House Officer accompanying the consultant .
2. Nursing staff had no clinical instruction as to how to manage the NG tube.
3. Nursing staff dealing with the patient were agency staff without training or experience of NG tube management.
4. Concerns regarding the NG tube function were not properly escalated to clinical staff.
” Open source report
9 Nov 2020 Joseph Hargreaves · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Reduced provision of information about events leading up to admission and baseline and underlying health issues to treating clinicians 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
Joseph Hargreaves · 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
Joseph Hargreaves had an unwitnessed fall at his care home and was admitted to hospital with sepsis due to aspiration pneumonia associated with poor swallowing. He initially appeared to improve but deteriorated rapidly and died on 17 April 2020. The report identified concerns about reduced information-sharing with treating clinicians regarding the events before admission and his baseline and underlying health issues, particularly when family members could not visit during lockdown.
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 Reduced provision of information about events leading up to admission and baseline and underlying health issues to treating clinicians
Wider context from the report “The provision of information, about the events leading up to his admission; his baseline and underlying health issues, to treating clinicians was reduced. In his case it did not impact the outcome however it was clear from the evidence that it could in other circumstances cause significant challenges in delivering effective treatment quickly to vulnerable patients .
” Open source report
12 Oct 2020 Piotr Kierzkowski · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 2 Insufficient provision to temporarily house patients awaiting informal admission View source Insufficient bed capacity for patients seeking informal admission View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Piotr Kierzkowski · 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
Piotr Kierzkowski was found deceased at home on 17 December 2019 after experiencing a mental health crisis and being assessed for admission to a psychiatric unit. No bed was available, so he was sent home with a friend and took his own life before he could return to hospital. The principal concerns were overall bed capacity for people seeking informal admission and arrangements for temporarily housing a patient when a bed is unavailable.
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 provision to temporarily house patients awaiting informal admission
Wider context from the report “In evidence it was heard that Piotr had not received his ‘depot’ medication for some time and was clearly suffering from a psychotic episode at the time of his assessment at the Accident and Emergency department of the West Suffolk Hospital on the 16th December 2019
Piotr told staff he was not actively suicidal at that point in time, and although the staff were concerned about his presentation, under mental health law least restrictive principles, they did not believe the powers of detention under the Mental Health Act were applicable.
That said, it was also clear from the evidence that the mental health personnel who saw Piotr wanted to immediately admit him as an informal patient.
It was also clear that when Piotr attended hospital on the 16th December 2019, he too wanted to be immediately admitted as an informal patient.
As a result, staff tried to locate a bed for Piotr so he could be admitted as all involved wished. However, it was identified that there were no beds available in Suffolk, or anywhere else in the country at the time.
Different options of keeping Piotr in the hospital were explored but none were viable.
As such, Piotr was prescribed medication to reduce his immediate anxiety and sent home with a friend, with instructions to return if his symptoms deteriorated.
Piotr took his own life the next morning before he could be returned to hospital.
Had a bed been available and Piotr had been admitted as he and medical staff had wished on the evening of the 16th December 2019, his death would not have occurred.
I am therefore concerned in relation to the overall bed capacity for those patients like Piotr seeking informal admission.
In addition, I am concerned about the provisions to temporarily house a patient wishing informal admission in the circumstances that a bed is not immediately available.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient bed capacity for patients seeking informal admission
Wider context from the report “In evidence it was heard that Piotr had not received his ‘depot’ medication for some time and was clearly suffering from a psychotic episode at the time of his assessment at the Accident and Emergency department of the West Suffolk Hospital on the 16th December 2019
Piotr told staff he was not actively suicidal at that point in time, and although the staff were concerned about his presentation, under mental health law least restrictive principles, they did not believe the powers of detention under the Mental Health Act were applicable.
That said, it was also clear from the evidence that the mental health personnel who saw Piotr wanted to immediately admit him as an informal patient.
It was also clear that when Piotr attended hospital on the 16th December 2019, he too wanted to be immediately admitted as an informal patient.
As a result, staff tried to locate a bed for Piotr so he could be admitted as all involved wished. However, it was identified that there were no beds available in Suffolk, or anywhere else in the country at the time .
Different options of keeping Piotr in the hospital were explored but none were viable.
As such, Piotr was prescribed medication to reduce his immediate anxiety and sent home with a friend, with instructions to return if his symptoms deteriorated.
Piotr took his own life the next morning before he could be returned to hospital.
Had a bed been available and Piotr had been admitted as he and medical staff had wished on the evening of the 16th December 2019, his death would not have occurred.
I am therefore concerned in relation to the overall bed capacity for those patients like Piotr seeking informal admission.
In addition, I am concerned about the provisions to temporarily house a patient wishing informal admission in the circumstances that a bed is not immediately available.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide national and regional improvement support to services reducing out-of-area placements.
Verbatim wording from the response “National and regional support has been provided to mental health services working to reduce out of area placements, with a particular focus on those areas that have been the most challenged. This includes clinically-led, bespoke improvement support and ensuring that strategies are in place to invest in community services and alternatives to admission.” Source location 2020-0204-Response-from-Department-of-Health-and-Social-Care_Redacted.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 Provide £50 million of strengthened post-discharge mental health support during the winter COVID-19 pressures.
Verbatim wording from the response “In recognition of the additional service pressures this winter resulting from the COVID-19 pandemic, an additional £50million is being provided to deliver strengthened support for mental health patients following their discharge from inpatient care over the coming months. This will be used to ensure that patients who are ready to leave inpatient facilities” Source location 2020-0204-Response-from-Department-of-Health-and-Social-Care_Redacted.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 End reliance on adult acute out-of-area placements by April 2021.
Verbatim wording from the response “There are a number of key commitments that support this aim, most notably the national policy to end reliance on adult acute out of area placements by April 2021. This commitment aims to ensure that all local mental health systems are operating effectively, with sufficient local bed capacity so that everyone can be admitted close to home and at the right time.” Source location 2020-0204-Response-from-Department-of-Health-and-Social-Care_Redacted.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 Urgent mental-health admission does not require detention under the Mental Health Act to access a bed quickly.
Verbatim wording from the response “However, patient safety is the first priority and NHSE/I, as system leader, is clear that if an urgent admission is required and a local bed is not available, mental health providers should seek and secure a placement out of area. You may wish to note that it is not the case that detention under the Mental Health Act is required to access a bed quickly.” Source location 2020-0204-Response-from-Department-of-Health-and-Social-Care_Redacted.pdf
Open published response
30 Sep 2020 Joseph Michael Cheetham · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of acute hospital bed capacity View source Failure to provide suitable waiting conditions in A and E View source Delays in putting care packages in place for medically optimised patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joseph Michael Cheetham · 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
Joseph Michael Cheetham suffered an unwitnessed accidental fall, underwent surgery for a dislocated prosthetic hip, and later died in hospital on 22 January 2020 after pneumonia, dysphagia and respiratory deterioration. Concerns included prolonged waiting in the Emergency Department because of bed shortages and discharge home before a care package was in place, while he was frail and vulnerable and had lost weight in 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 Lack of acute hospital bed capacity
Wider context from the report “1. The inquest heard that his GP had sought to have him admitted directly into hospital having identified that he needed to be hospitalised. However, contact with the trust identified that the acute bed shortage meant that this would not be possible , and he would have to go via A and E. On arrival at A and E the volume of those waiting to be seen meant that he waited in cold and draughty areas of the department. Lack of bed capacity in the hospital meant that he spent over 24 hours in the A and E department despite being frail and vulnerable.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 suitable waiting conditions in A and E
Wider context from the report “1. The inquest heard that his GP had sought to have him admitted directly into hospital having identified that he needed to be hospitalised. However, contact with the trust identified that the acute bed shortage meant that this would not be possible, and he would have to go via A and E. On arrival at A and E the volume of those waiting to be seen meant that he waited in cold and draughty areas of the department . Lack of bed capacity in the hospital meant that he spent over 24 hours in the A and E department despite being frail and vulnerable.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 putting care packages in place for medically optimised patients
Wider context from the report “2. The inquest heard that he was medically optimised, and he had lost weight in hospital whilst awaiting a care package to be put in place . One was still not in place by 24th December and it was likely to be at least another 2-3 weeks before one was in place . To avoid further deconditioning and weight loss in an acute setting whilst awaiting a care package his family took on caring for him at home to facilitate a discharge.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue rolling out Urgent Treatment Centres to provide a consistent urgent-care service.
Verbatim wording from the response “In 2019/20, this involved continued work to tackle both the increases in demand in urgent and emergency care and to ensure patients receive the quality of care they need and expect in a timely and safe manner. For example, the continued roll out of Urgent Treatment Centres, offering a consistent service to patients and introducing the ability to book appointments through NHS 111, as well as initiatives such as Same Day Emergency Care, to reduce non-elective admissions to hospital.” Source location 2020-0189-Response-from-Dept.-of-Health-and-Social-Care_Redacted.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 Allocate additional capital funding, including £3.611 million for Stepping Hill Hospital’s emergency-department upgrade.
Verbatim wording from the response “NHS Trusts across England, including the Stockport NHS Foundation Trust, will receive a share of £450million additional capital funding to upgrade their facilities ahead of this winter and ensure the NHS is prepared to cope with winter pressures and reduce the risks associated with further outbreaks of Covid-19. Stepping Hill Hospital, Stockport is being allocated £3,611,000 of this funding to upgrade its emergency department.” Source location 2020-0189-Response-from-Dept.-of-Health-and-Social-Care_Redacted.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 Continue Same Day Emergency Care initiatives to reduce non-elective hospital admissions.
Verbatim wording from the response “In 2019/20, this involved continued work to tackle both the increases in demand in urgent and emergency care and to ensure patients receive the quality of care they need and expect in a timely and safe manner. For example, the continued roll out of Urgent Treatment Centres, offering a consistent service to patients and introducing the ability to book appointments through NHS 111, as well as initiatives such as Same Day Emergency Care, to reduce non-elective admissions to hospital.” Source location 2020-0189-Response-from-Dept.-of-Health-and-Social-Care_Redacted.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 NHS 111 to provide urgent-care advice and direct patients to appropriate services more quickly.
Verbatim wording from the response “Other elements of the NHS winter plan for 2020/21 include the expansion of NHS 111 to support patients who need urgent care advice and direct them to the right service more quickly, rather than waiting in A&E².” Source location 2020-0189-Response-from-Dept.-of-Health-and-Social-Care_Redacted.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 Make £1.3 billion available and confirm £588 million to support enhanced hospital-discharge arrangements over winter.
Verbatim wording from the response “This year we made £1.3billion funding available via the NHS to support the hospital discharge process in March. As part of the £3.6billion funding for winter, an extra £588million was confirmed to continue enhanced discharge arrangements over winter and maintain the safe and timely discharge of patients from hospital.” Source location 2020-0189-Response-from-Dept.-of-Health-and-Social-Care_Redacted.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 Maintain Nightingale Hospitals, their surge capacity and NHS use of independent-sector hospital capacity.
Verbatim wording from the response “This year, we have provided an extra £3billion to alleviate the particular challenges brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale Hospitals and their surge capacity, as well as the NHS’s use of independent sector hospital capacity.” Source location 2020-0189-Response-from-Dept.-of-Health-and-Social-Care_Redacted.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 NHS providers and local partners, including social services, are responsible for timely discharge planning and post-discharge care.
Verbatim wording from the response “It is the responsibility of the NHS and its local partners, including social service departments, to ensure that no patient remains in a hospital bed for longer than clinically necessary and that any ongoing care and support can begin promptly. NHS providers are expected to begin planning for a person’s discharge at the point of admission, which should include practical arrangements, care requirements and where the person is being discharged to. The hospital should involve local social services at the earliest opportunity to plan post-discharge care and avoid delays.” Source location 2020-0189-Response-from-Dept.-of-Health-and-Social-Care_Redacted.pdf
Open published response
28 Sep 2020 Mr William Ivan McKibbin · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Lack of documentation checks confirming bed brakes are on View source Failure to maintain a culture in which staff can speak up about errors and poor practice View source Lack of a minimum-information standard for cross-hospital specialist advice communication View source Lack of guidance for identifying, securing and gathering evidence in clinical incident investigations View source Failure of the Statutory Notification process to require timely submission of relevant evidence about deaths View source Unavailability of medical records across Trust hospital sites View source Lack of documentation checks confirming bed-rails are in the appropriate position 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
Mr William Ivan McKibbin · 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 William Ivan McKibbin died at Trafford General Hospital on 20 August 2018 following complications of a traumatic brain injury sustained in an unwitnessed fall in hospital. The report raised concerns about bed-rail and bed-brake checks, the culture of openness and candour, communication between specialists and hospital sites, incident investigations, and the process for learning from 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 documentation checks confirming bed brakes are on
Wider context from the report “2. It is a matter of concern that NHS nursing documentation, such as Intentional Rounding Checklists, in use at the Trust and in other hospitals, currently do not include ‘tick-box’ checks to confirm bed-rails are in the appropriate position, and the bed brakes are on .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a culture in which staff can speak up about errors and poor practice
Wider context from the report “1. The evidence heard at this inquest left me with residual concerns as to the prevailing culture at the Trust, and by extension, within the NHS .
It was clear from the evidence that by the time of Mr McKibbin’s death, Managers from the Trust were aware at the very least that the brakes simply cannot have been applied to his bed at the time he sustained the fall which led to his death.
Despite this, no confirmation of this fact was made to Mr McKibbin’s family, or in the report of his death to the Coroner. Similarly, this conclusion was not drawn by a number of internal investigations undertaken by the Trust, or indeed in evidence given to the court by Professor ████████, Chief Nurse and a member of the Trust’s board.
For a duty of candour to have meaning, it is essential the prevailing culture of an organisation is one where staff have freedom to speak out. For the reasons set out by Sir ████████ QC in his PFD Report into events at Mid Staffordshire NHS Foundation Trust, unless staff of all levels feel able to speak up about their own errors, and to point out to highlight poor practice of others, a significant risk of future deaths will remain .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 minimum-information standard for cross-hospital specialist advice communication
Wider context from the report “3. Given the operating model of the Trust, whereby different specialists provide services at different hospitals, it is a matter of concern that no proforma documentation / communication paradigm exists which sets out the minimum standard of information expected to be conveyed when a clinician seeks advice from a specialist based at another hospital .
The risk of death in this regard is currently compounded by the fact that medical records from one hospital are not necessarily accessible from another site within the Trust group.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for identifying, securing and gathering evidence in clinical incident investigations
Wider context from the report “4. In view of the importance of robust and reliable investigations into clinical incidents to reducing the risk of future deaths, it is a matter of concern that no guidance currently exists for on-call managers and investigators as to quickly identifying, securing and gathering relevant evidence .
Improvements in gathering evidence would assist the Trust in reliably identifying the underlying cause or causes of incidents, which in turn would better inform actions to be taken with a view to reducing the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of the Statutory Notification process to require timely submission of relevant evidence about deaths
Wider context from the report “5. In order to enhance learning from deaths, consideration should be given to modifying the Statutory Notification process following death of a service-user so as to require Registered Providers to lodge specified relevant evidence as to how the death occurred within a defined period .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of medical records across Trust hospital sites
Wider context from the report “3. Given the operating model of the Trust, whereby different specialists provide services at different hospitals, it is a matter of concern that no proforma documentation / communication paradigm exists which sets out the minimum standard of information expected to be conveyed when a clinician seeks advice from a specialist based at another hospital.
The risk of death in this regard is currently compounded by the fact that medical records from one hospital are not necessarily accessible from another site within the Trust group .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 documentation checks confirming bed-rails are in the appropriate position
Wider context from the report “2. It is a matter of concern that NHS nursing documentation, such as Intentional Rounding Checklists, in use at the Trust and in other hospitals, currently do not include ‘tick-box’ checks to confirm bed-rails are in the appropriate position , and the bed brakes are on.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust’s Duty of Candour policy and reported compliance, rated Good by the CQC, are considered sufficient arrangements for openness and transparency.
Verbatim wording from the response “I note your residual concerns as to the prevailing culture at the Trust, and by extension, within the NHS with regard to the Duty of Candour.” Source location 2020-0185-Response-from-Dept.-of-Health-and-Social-Care-Redacted.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current NRLS and STEIS reporting processes are considered adequate for the CQC to fulfil its regulatory responsibilities.
Verbatim wording from the response “In relation to the matter of concern about notification requirements in relation to the deaths of service users and the information that is required of providers within a specified time period, I am aware that the CQC has written to you explaining the process for the reporting of deaths, or incidents of ‘severe harm’, to NHSE/I’s National Reporting and Learning System (NRLS) and STEIS (the strategic executive information system), and the way in which the CQC can review, request and assess information relating to reported incidents.” Source location 2020-0185-Response-from-Dept.-of-Health-and-Social-Care-Redacted.pdf
Open published response
25 Sep 2020 Susan Warby · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 2 Insufficiently distinctive packaging and visual identification of intravenous fluids for arterial line transducer sets View source Failure to use the correct technique when drawing blood samples from arterial lines View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Susan Warby · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Susan Warby was admitted to hospital with a perforated bowel and underwent emergency surgery. An incorrect intravenous fluid attached to an arterial line, combined with incorrect blood-sampling technique, produced erroneous results that led to unnecessary insulin treatment, hypoglycaemia and a brain injury; her death followed multi-organ failure, septicaemia and disseminated aspergillus pneumonia. The principal concerns were the lack of distinctive labelling for fluids used with arterial lines and inadequate blood-sampling technique and training.
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 Insufficiently distinctive packaging and visual identification of intravenous fluids for arterial line transducer sets
Wider context from the report “1. During the evidence it was clear that packaging and visual identification aids available for intravenous fluids to be used in arterial line transducer sets were not sufficiently distinctive .
It was heard that following Mrs Warby's death that as far as possible the West Suffolk Hospital has asked its suppliers to change the labelling on the intravenous fluids it purchases. These were exhibited in court and even with the changes the manufacture was prepared to make, the packaging cannot be considered at all distinctive for fluids to be used in an arterial line .
In direct contrast, we saw that the tubing used on an arterial line transducer set has a solid red line running its length. This is to clearly indicate to staff that it is an arterial line therefore must not be used for the administration of drugs or medicinal fluids.
I am therefore concerned that the packaging of the 0.9% Sodium Chloride intravenous fluid to be used with an arterial line is not also so clearly distinguished. It was heard in evidence that there is currently no 0.9% Sodium Chloride intravenous fluid available which is specifically and clearly labelled for arterial line use only .
It is important to note that the issue identified in this inquest regarding the use of incorrect intravenous fluid in an arterial line is not a new one. In 2008 the UK National Patient Safety Agency issued a Rapid Response report highlighting problems with infusions and sampling from arterial lines. In that 2008 report the UK National Patient Safety Agency had already identified 84 incidents where the wrong infusion was attached to an arterial line with two of those cases proving fatal.
It is understood that the 0.9% Sodium Chloride intravenous fluid has a number of medicinal uses other than just as a flushing fluid in an arterial line. However, the number of cases identified where the incorrect fluid is being used in arterial lines, clearly demonstrates the confusion and errors which occur when using generally labelled intravenous fluids with an arterial line transusion set .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 the correct technique when drawing blood samples from arterial lines
Wider context from the report “2. The court was told that the medical staff taking blood samples from the arterial line transducer sets were not using the correct technique to ensure erroneous blood samples were not taken .
The court heard that even if the incorrect intravenous fluid is fitted to an arterial line, a good technique used by staff (ensuring to fully account for the ‘dead space’ when drawing the blood sample) would prevent false readings being obtained .
As such, in Mrs Warby's case the error of the incorrect intravenous fluid being fitted to her arterial line was exacerbated by medical staff using an incorrect technique when drawing her blood samples.
The court was told that training in drawing blood from an arterial line is given as part of standard training for staff caring for patients with an arterial line in place. However, there were a number of erroneous samples taken in Mrs Warby's case, these samples being taken by a number of different staff .
As such, the West Suffolk Hospital has already implemented new training and operational regimes for its staff.
However, given the apparent prevalence of errors regarding the incorrect use of intravenous fluids and incorrect blood sampling techniques involving arterial lines , a review of training and operational regimes may be considered necessary on a wider basis.
” 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 Relevant professional bodies are responsible for education and training matters concerning arterial-line competencies.
Verbatim wording from the response “I hope this clarification is helpful. Education and training are also matters for the relevant professional bodies and my officials have brought the matters of concern in your report to the attention of the Nursing and Midwifery Council and the General Medical Council for their information and consideration.” Source location 2020-0188-Response-from-Dept.-of-Health-and-Social-Care-Redacted.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 Employers are responsible for providing post-registration arterial-line training and blood-sampling training to relevant staff.
Verbatim wording from the response “For nurses, this is a post-registration competency for which the employer has a responsibility to provide training. It is not an expected competency for undergraduate nursing. I am further advised that medical students would not be expected to have this competency and it is not contained in the curriculum for medical undergraduate training. The insertion of arterial cannula is contained in a small number of postgraduate medical curricula and the competencies are assessed and monitored through standard educational procedures.” Source location 2020-0188-Response-from-Dept.-of-Health-and-Social-Care-Redacted.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 Colour cannot be used in IV-fluid labelling because container manufacturing prevents it; other local risk controls are required.
Verbatim wording from the response “You will also know that the MHRA has explained that the way in which the containers of the IV fluids described in your report are manufactured (bags composed of polyolefin/polyamide co-extruded plastic), means that judicious use of colour cannot be used within the labelling to aid differentiation and reduce the likelihood of error at the point of selection. The MHRA states that other risk minimisation measures should be employed locally within clinical areas to assist correct identification. However, the MHRA has undertaken to consider further with the marketing authorisation holder whether improvements can be made to the labelling to help ensure the medicine is used appropriately and reduce the likelihood of such errors in future.” Source location 2020-0188-Response-from-Dept.-of-Health-and-Social-Care-Redacted.pdf
Open published response
Concerns raised 3 Insufficient WAST resources to meet stroke response targets View source Lack of a specific time target for stroke care View source Inappropriate grading of stroke patients falling in the amber category 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
Andres Roberts · 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
Andres Roberts suffered a large stroke and was taken to Morriston Hospital after four emergency calls, with the ambulance arriving 2 hours and 20 minutes after the incident was reported. He received thrombolysis and later suffered a large intracranial bleed before dying at the hospital. Concerns included the grading of acute stroke patients, whether a specific response-time target should be set, and whether additional ambulance resources were needed.
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 WAST resources to meet stroke response targets
Wider context from the report “(1) In an acute stroke 'time is brain' which means that the sooner thrombolysis (clot busting drug) is administered the better are the chances of recovery and subsequent survival. The deceased was thrombolysed with 4.5 hours of stroke onset, however, based on research and clinical data if the patient was to arrive in A&E sooner then he would have received the above mentioned treatment earlier which may have affected the outcome. Unfortunately, the stroke consultant was unable to comment on the exact likelihood of a different outcome as "he did have a big stroke to begin with and each patient reacts differently to the treatment"
(2) My concerns centre on :-
A) the appropriateness of the grading of stroke patients falling in the amber category and
B) whether a specific time target should be set and
C) whether additional resources should be made available to WAST to meet these targets
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 specific time target for stroke care
Wider context from the report “(1) In an acute stroke 'time is brain' which means that the sooner thrombolysis (clot busting drug) is administered the better are the chances of recovery and subsequent survival. The deceased was thrombolysed with 4.5 hours of stroke onset, however, based on research and clinical data if the patient was to arrive in A&E sooner then he would have received the above mentioned treatment earlier which may have affected the outcome. Unfortunately, the stroke consultant was unable to comment on the exact likelihood of a different outcome as "he did have a big stroke to begin with and each patient reacts differently to the treatment"
(2) My concerns centre on :-
A) the appropriateness of the grading of stroke patients falling in the amber category and
B) whether a specific time target should be set and
C) whether additional resources should be made available to WAST to meet these targets
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 grading of stroke patients falling in the amber category
Wider context from the report “(1) In an acute stroke 'time is brain' which means that the sooner thrombolysis (clot busting drug) is administered the better are the chances of recovery and subsequent survival. The deceased was thrombolysed with 4.5 hours of stroke onset, however, based on research and clinical data if the patient was to arrive in A&E sooner then he would have received the above mentioned treatment earlier which may have affected the outcome. Unfortunately, the stroke consultant was unable to comment on the exact likelihood of a different outcome as "he did have a big stroke to begin with and each patient reacts differently to the treatment"
(2) My concerns centre on :-
A) the appropriateness of the grading of stroke patients falling in the amber category and
B) whether a specific time target should be set and
C) whether additional resources should be made available to WAST to meet these targets
” Open source report
18 Sep 2020 Joseph Francis Luke Nihill · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 5 Active promotion of a method of committing suicide View source Risk of individuals being drawn into a deteriorating cycle through discussion of suicide methods View source Sites bestowing legitimacy on self-harming behaviour View source Availability and promotion of potentially lethal substances as a method of killing oneself View source Discussions with troubled and vulnerable young men undermining treatment and family efforts to restore health View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Joseph Francis Luke Nihill · 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
On 4 April 2020, Joseph Francis Luke Nihill, aged 23, was found dead at his mother’s home after taking a substance to end his life; the inquest concluded that his death was suicide caused by toxicity. The principal concerns were that an online contact provided advice on suicide methods and that potentially lethal substances were made available and promoted for this purpose.
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 Active promotion of a method of committing suicide
Wider context from the report “(1) ████████ may be actively promoting a particular method of committing suicide and hence breaking the criminal law by assisting suicide. Consideration should be given to blocking their availability in the UK so as to negate this 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 Risk of individuals being drawn into a deteriorating cycle through discussion of suicide methods
Wider context from the report “(3) At a time when society is seeking to safeguard the mental health particularly of young men suffering from depression, it is counterproductive to permit such sites to bestow a legitimacy on self-harming behaviour. There is a foreseeable risk that other individuals will be drawn into a deteriorating cycle by discussing methods of ending their lives .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Sites bestowing legitimacy on self-harming behaviour
Wider context from the report “(3) At a time when society is seeking to safeguard the mental health particularly of young men suffering from depression, it is counterproductive to permit such sites to bestow a legitimacy on self-harming behaviour . There is a foreseeable risk that other individuals will be drawn into a deteriorating cycle by discussing methods of ending their lives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Availability and promotion of potentially lethal substances as a method of killing oneself
Wider context from the report “(4) It is harmful for potentially lethal substances to be made available and promoted as an effective method of killing oneself . In this case, Joe was told ████████ could be obtained for £8. Those supplying relatively small amounts of ████████ should be made aware of the implications of their trade.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Discussions with troubled and vulnerable young men undermining treatment and family efforts to restore health
Wider context from the report “(2) ████████ which enter discussions with troubled and vulnerable young men such as Joe Nihill serve to undermine the benefit of both the medical treatment provided to him and the constructive efforts of his family to restore his health . They have no social utility, but do have the potential to cause harm .
” Open source report
14 Sep 2020 Isaac Jakob NEWTON · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 1 Continuation of unsafe sleeping practices by parents View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Isaac Jakob NEWTON · 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
Isaac Newton was a previously healthy four-month-old baby who died after being placed in a double bed and sleeping alongside his father and half-sibling. He was found unresponsive the following morning, and the inquest recorded that his airway was obstructed by the weight of an adult body overlying him, depriving him of oxygen. The principal concern was the risk to young infants from unsafe sleeping practices, including co-sleeping with adults or older children and potential impairment from drug or alcohol use.
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 Continuation of unsafe sleeping practices by parents
Wider context from the report “(1)My concern relates to the risk posed to young infants by unsafe sleeping practices. This inquest involved a young child who was sleeping in a bed with a Parent and a Half – sibling. This was the fourth inquest I have concluded in 2020 that has involved a child that has died whilst sleeping in or on the parental bed. All of these inquests have involved relatively young parents. In three of the four inquests alcohol or drug use was a factor.
Although guidance is provided to new parents about the dangers posed by an unsafe sleeping environment, I am concerned that the message is not being appreciated and / or followed .
The evidence received from Isaac’s Parents was illustrative. His Mother informed the court that she had received advice from health visitors about the potential risks of a child co-sleeping with an adult but had clearly chosen not to follow the advice despite having a suitable cot available for him to sleep in. Isaac’s Father by contrast told the court that he could not recall receiving such advice. He gave the impression that he was unaware that the child may be at risk were he to use cannabis before co-sleeping, and in preferring to co – sleep rather than place Isaac in the cot he was following the practice he knew Isaac’s Mother adopted when Isaac was residing with her.
Isaac’s Mother gave the impression that Isaac was not in jeopardy when he slept with her and his Half – sibling during the night because there was no risk that she would unknowingly roll over during the night.
I am concerned that despite efforts to provide guidance to parents about what may amount to an unsafe sleeping environment some parents are continuing to place often very young children at risk . I concluded that it would be remiss of me as Senior Coroner for this coronial area were I not to raise this concern in light of the number of inquests we have concluded during which an unsafe sleeping environment has been adjudged to have played a role in the child’s death.
I am aware that the Department of Health & Social Care did in July of this year publish details of a major review into improving health outcomes for babies and young children and so I have chosen to forward this letter to the Parliamentary Under Secretary with responsibility for that review as the concern I raise may be of relevance.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with stakeholders to develop shared tools and processes helping frontline professionals promote safer sleeping among families with children at risk.
Verbatim wording from the response “The report, which you have referenced, highlights that despite broad success embedding safer sleeping messages with parents, there are still persistent issues for some families when it comes to acting on those lessons. The report is clear that this is a complex issue. We will implement the three national recommendations:” Source location 2020-0174-Response-from-Dept-of-Health-and-Social-Care_Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider embedding learning from the review in the Healthy Child Programme’s transition-to-parenthood and early-weeks provision.
Verbatim wording from the response “The report, which you have referenced, highlights that despite broad success embedding safer sleeping messages with parents, there are still persistent issues for some families when it comes to acting on those lessons. The report is clear that this is a complex issue. We will implement the three national recommendations:” Source location 2020-0174-Response-from-Dept-of-Health-and-Social-Care_Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create and release short films promoting safe sleeping and co-sleeping advice during the pandemic and when babies will not sleep.
Verbatim wording from the response “To promote safe sleeping messages regarding babies and co-sleeping, Public Health England, working with the Lullaby Trust, have created two short films that have been released this year. The films give advice on caring for babies during the Covid-19 pandemic⁵, and when your baby won’t sleep⁶.” Source location 2020-0174-Response-from-Dept-of-Health-and-Social-Care_Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish refreshed Healthy Child Programme commissioning and delivery guidance incorporating safer-sleeping discussions at specified professional contacts.
Verbatim wording from the response “Public Health England advise that in Quarter 3, 2020/21, it plans to publish refreshed commissioning and delivery guidance for the Healthy Child Programme, that includes safer sleeping discussions at specific interactions between health visitors and school nurses with parents and carers. In addition, Public Health England plans to publish refreshed High Impact Areas for the Healthy Child Programme in Q3, 2020/21 which will highlight the potential for harm from new hazards such as cot bumpers and sleeping pods and the dangers associated with SIDS.” Source location 2020-0174-Response-from-Dept-of-Health-and-Social-Care_Redacted.pdf
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish refreshed Healthy Child Programme High Impact Areas guidance highlighting hazards including cot bumpers, sleeping pods and SIDS risks.
Verbatim wording from the response “Public Health England advise that in Quarter 3, 2020/21, it plans to publish refreshed commissioning and delivery guidance for the Healthy Child Programme, that includes safer sleeping discussions at specific interactions between health visitors and school nurses with parents and carers. In addition, Public Health England plans to publish refreshed High Impact Areas for the Healthy Child Programme in Q3, 2020/21 which will highlight the potential for harm from new hazards such as cot bumpers and sleeping pods and the dangers associated with SIDS.” Source location 2020-0174-Response-from-Dept-of-Health-and-Social-Care_Redacted.pdf
Open published response
Concerns raised 2 Failure to scrutinise repeat prescription requests View source Electronic prescribing systems failing to direct prescribers to relevant medical records and the ‘Active Problems’ section View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Laura Eve PARSONS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Laura Eve Parsons was found dead at home on 5 November 2019, after consuming a fatal amount of liquid morphine prescribed for breakthrough cancer pain. She had previously been admitted to hospital following an accidental morphine overdose, but a repeat prescription was later issued without the electronic prescribing system directing the prescriber to review the prominent medical-record information about that overdose.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to scrutinise repeat prescription requests
Wider context from the report “Ms Parsons was prescribed liquid morphine to treat ‘break through’ pain for cancer. It was first prescribed on 9th August 2019. Ms Parsons was admitted to hospital on 10th August 2019 with an accidental overdose of morphine. It appears 180mls were consumed in a 12 hour period. She recovered and was discharged from hospital. The remainder of the prescribed morphine was discarded.
On 31st October 2019 Ms Parsons requested a repeat prescription of liquid morphine from her GP surgery. This was authorised and a 500ml bottle of liquid morphine was dispensed to Ms Parsons. On 5th November 2019 Ms Parsons was found dead due to ingesting a fatal amount of morphine.
At inquest evidence was given that information such as recent overdose would be added to the ‘Active Problems’ section on a person’s medical records and would be prominent when any clinician accessed that person’s records.
It was explained at inquest that when a patient applies for a repeat prescription so far as the request is within the permitted timescale to issue a repeat of the prescribed item, then the prescription would be issued without any further scrutiny and the electronic systems would not take a prescriber to the patient’s medical records and in particular the ‘Active Problems’ section.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Electronic prescribing systems failing to direct prescribers to relevant medical records and the ‘Active Problems’ section
Wider context from the report “Ms Parsons was prescribed liquid morphine to treat ‘break through’ pain for cancer. It was first prescribed on 9th August 2019. Ms Parsons was admitted to hospital on 10th August 2019 with an accidental overdose of morphine. It appears 180mls were consumed in a 12 hour period. She recovered and was discharged from hospital. The remainder of the prescribed morphine was discarded.
On 31st October 2019 Ms Parsons requested a repeat prescription of liquid morphine from her GP surgery. This was authorised and a 500ml bottle of liquid morphine was dispensed to Ms Parsons. On 5th November 2019 Ms Parsons was found dead due to ingesting a fatal amount of morphine.
At inquest evidence was given that information such as recent overdose would be added to the ‘Active Problems’ section on a person’s medical records and would be prominent when any clinician accessed that person’s records.
It was explained at inquest that when a patient applies for a repeat prescription so far as the request is within the permitted timescale to issue a repeat of the prescribed item, then the prescription would be issued without any further scrutiny and the electronic systems would not take a prescriber to the patient’s medical records and in particular the ‘Active Problems’ section .
” Open source report
17 Aug 2020 Ian Allen · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 6 Lack of clear national guidance on clozapine monitoring frequency and blood test type View source Lack of a system for escalating blood test results to the consultant View source Lack of understanding of the importance and frequency of clozapine level monitoring View source Failure to act on high clozapine blood test results through repeat testing and dose adjustment View source Insufficient education of Mental Health practitioners on clozapine monitoring and level adjustment View source Lack of understanding of clozapine monitoring, blood test selection and drug effects View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ian Allen · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ian Allen collapsed suddenly at the nursing home where he resided on 31 December 2019 and died soon after arriving at hospital. The medical cause of death was clozapine toxicity. Concerns included a high clozapine blood level not being acted upon, inadequate monitoring and dose adjustment after smoking cessation, and the absence of a system to escalate blood test results to the consultant.
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 clear national guidance on clozapine monitoring frequency and blood test type
Wider context from the report “4. I heard evidence at the inquest that there was a general lack of understanding about clozapine monitoring, which blood test to undertake and the general effect this drug can have on patients. I heard evidence that national guidance was required to clearly set out how frequently clozapine levels should be monitored and what type of blood test should be undertaken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for escalating blood test results to the consultant
Wider context from the report “2. There was no system in place at the time to ensure blood test results were escalated to the consultant to ensure action was taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the importance and frequency of clozapine level monitoring
Wider context from the report “3. There was a general lack of understanding at the inquest about the importance of monitoring clozapine levels and how frequently these levels should be monitored.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to act on high clozapine blood test results through repeat testing and dose adjustment
Wider context from the report “1. In February 2019 a blood test result confirmed that Mr Allen had a high level of clozapine in his blood. This was not acted upon and no further blood test was taken. The clozapine dose was not adjusted as it should have been.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 education of Mental Health practitioners on clozapine monitoring and level adjustment
Wider context from the report “5. Further education is required of Mental Health practitioners on the importance of clozapine monitoring and level adjustment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of clozapine monitoring, blood test selection and drug effects
Wider context from the report “4. I heard evidence at the inquest that there was a general lack of understanding about clozapine monitoring, which blood test to undertake and the general effect this drug can have on patients. I heard evidence that national guidance was required to clearly set out how frequently clozapine levels should be monitored and what type of blood test should be undertaken.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Routine therapeutic drug monitoring of clozapine blood levels is not required; authorised product information specifies monitoring requirements and toxicity-related exceptions.
Verbatim wording from the response “The patient monitoring requirements for clozapine include the measurement of clinical parameters such as regular full blood counts; blood pressure; electrocardiograms; hepatic enzymes; blood sugar, lipids and weight. Therapeutic drug monitoring of blood plasma levels is not currently required under the terms of the clozapine marketing authorisation.” Source location 2020-0161-Response-from-Dept-Health-and-Social-Care_Redacted.pdf
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NICE guideline 178 does not require updating because clozapine toxicity risks are detailed in the BNF and authorised product information.
Verbatim wording from the response “NICE advises that while it is recognised that the current recommendations in the NICE guideline may not fully take account of the adverse effects and risks of toxicity associated with the use of clozapine, these are specified in detail in the British National Formulary⁷ and, as already explained, the SmPC for prescribers which contains advice on interactions that can influence blood levels of clozapine.” Source location 2020-0161-Response-from-Dept-Health-and-Social-Care_Redacted.pdf
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations