Concerns raised 1 Insufficient systems for collating an appropriate antibiotic history for patients coming from a distance 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 Kay Morrison · 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 Kay Morrison underwent necessary surgery at the Royal Hallamshire Hospital on 11 June 2015, developed severe bacterial and fungal infections, and died of sepsis on 21 June 2015. The principal concern was that no proper antibiotic history was obtained, amid insufficient systems for collating such histories, resulting in antibiotics being prescribed for prophylaxis and treatment that were not effective for their intended purpose.
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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 Insufficient systems for collating an appropriate antibiotic history for patients coming from a distance
Wider context from the report “a) The evidence showed that there was insufficient system to ensure the collation of an appropriate antibiotic history . The Hospital Trust concerned avows that it has rectified this issue but it seems likely that many other hospitals may be in the same position if patients are coming from a distance .
” Open source report
15 Feb 2018 Bethany Victory Shipsey · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 3 Unrestricted internet availability of dinitrophenol View source Increasing popularity of dinitrophenol as a diet pill among young people View source Extreme toxicity of dinitrophenol without a known antidote 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
Bethany Victory Shipsey · 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
Bethany Victory Shipsey, a young woman with significant mental health difficulties, died by suicide on 15 February 2017 after deliberately ingesting tablets containing dinitrophenol purchased over the Internet. The report identified significant failings in hospital monitoring and supportive care, and raised concern that dinitrophenol was extremely toxic, had no known antidote, and was freely available online.
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 internet availability of dinitrophenol
Wider context from the report “(1) : The inquest heard evidence from Prof Simon Thomas, the national clinical lead for Toxbase and acknowledged expert in dinitrophenol toxicity. His unchallenged evidence was that DNP is extremely toxic, with no known antidote and that it is becoming increasingly popular with young people as a “diet pill” and is freely available via the Internet .
There fatalities ████████ steps are taken to make it illegal to possess, sell or supply the drug. Given the tragic death of Ms Shipsey in the circumstances outlined above I invite the Secretary of State for Health to consider introducing legislation to make illegal the possession and supply of DNP.
(2)
(3)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Increasing popularity of dinitrophenol as a diet pill among young people
Wider context from the report “(1) : The inquest heard evidence from Prof Simon Thomas, the national clinical lead for Toxbase and acknowledged expert in dinitrophenol toxicity. His unchallenged evidence was that DNP is extremely toxic, with no known antidote and that it is becoming increasingly popular with young people as a “diet pill” and is freely available via the Internet.
There fatalities ████████ steps are taken to make it illegal to possess, sell or supply the drug. Given the tragic death of Ms Shipsey in the circumstances outlined above I invite the Secretary of State for Health to consider introducing legislation to make illegal the possession and supply of DNP.
(2)
(3)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Extreme toxicity of dinitrophenol without a known antidote
Wider context from the report “(1) : The inquest heard evidence from Prof Simon Thomas, the national clinical lead for Toxbase and acknowledged expert in dinitrophenol toxicity. His unchallenged evidence was that DNP is extremely toxic, with no known antidote and that it is becoming increasingly popular with young people as a “diet pill” and is freely available via the Internet.
There fatalities ████████ steps are taken to make it illegal to possess, sell or supply the drug. Given the tragic death of Ms Shipsey in the circumstances outlined above I invite the Secretary of State for Health to consider introducing legislation to make illegal the possession and supply of DNP.
(2)
(3)
” 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 DNP products intended to treat obesity fall within medicinal product regulation and are a matter for the MHRA.
Verbatim wording from the response “While diet pills and supplements are not typically regarded to be medicines, a product which is intended to treat an adverse medical condition such as obesity is likely to fall within the definition of a medicinal product and would be a matter for the Medicines and Healthcare Products Regulatory Agency (the MHRA).” Source location 2018-0049-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for DNP sold for human consumption falls to the Food Standards Agency under food safety legislation.
Verbatim wording from the response “As DNP has no medicinal or health benefit, if it sold for human consumption it becomes by default a food and is dealt with as a dangerous food under the Food Safety Act 1990. The lead for DNP therefore falls to the Food Standards Agency (the FSA).” Source location 2018-0049-Response-by-Department-of-Health
Open published response
12 Feb 2018 John William Sloan · Prevention of Future Deaths report London Inner (South)
View report summary
Concerns raised 2 Failure to record concerns raised by family members View source Failure to ask about suicidal ideas or suicide plans View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John William Sloan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John William Sloan died by suicide on 16 August 2017 after hanging himself while alone at home. He had been receiving mental health care for anxiety, depression, sleeplessness and suicidal ideation. The principal concerns were that he was not asked about suicidal thoughts or plans at his last face-to-face contact, and that information from his daughter about his distress was not recorded or acted upon.
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 record concerns raised by family members
Wider context from the report “(2) With regard to the contact with the Care co-ordinator on the 11/8/17 the failure to record the concerns of Mr Sloan’s daughter was a fundamental omission which also represented a missed opportunity to put in place supportive measures which may have prevented the death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ask about suicidal ideas or suicide plans
Wider context from the report “(1) With regard to the contact on the 8/8/17 I am concerned that the deceased was not asked whether he was experiencing suicidal ideas or had suicide plans . Whilst it is a matter of speculation as to whether he would have disclosed suicidal plans or ideas I consider that this was an error in the management of the deceased’s mental health condition and was a missed opportunity to put in place supportive measures if such thoughts had been disclosed.
” Open source report
25 Jan 2018 Sharon Rose Grierson · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 4 Lack of co-ordination View source Insufficient crisis-situation experience and maintenance of senior staff skills View source Lack of situational awareness View source Lack of understanding of capnography interpretation during CPR 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
Sharon Rose Grierson · 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
Sharon Rose Grierson, aged 44, underwent elective surgery to remove a benign vocal cord polyp and developed laryngospasm during extubation. Endotracheal tubes were twice placed in the oesophagus rather than the trachea, leading to oxygen deprivation, hypoxic brain injury and her death. Concerns included failure to appreciate capnography readings, lack of coordination and situational awareness, and limited experience of senior staff in crisis situations.
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 co-ordination
Wider context from the report “(2)There was a lack of co-ordination and situational awareness.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 crisis-situation experience and maintenance of senior staff skills
Wider context from the report “(3)It became apparent that senior staff often have little experience of crisis situations and there is a danger that they become ‘de-skilled’ to some extent as a result .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 situational awareness
Wider context from the report “(2)There was a lack of co-ordination and situational awareness .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 capnography interpretation during CPR
Wider context from the report “(1) There was a lack of appreciation of what the capnography was indicating and some lack of understanding of the trace one might expect to see during CPR .
” Open source report
19 Jan 2018 William Myers · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 8 Failure to circulate important clinical risk information to treating clinicians View source Failure to undertake multidisciplinary case conference reassessment by a forensic psychiatrist View source Inconsistent continuity of psychiatric care across teams and wards View source Failure to act on recommendations to consider Mental Health Act assessment View source Gaps in clinical record keeping hindering treatment coordination and discharge accountability View source Failure to identify complex cases early and assign them to an appropriately qualified psychiatrist View source Failure of psychiatric consultants to confer sufficiently on a clear management plan View source Insufficient availability of inpatient psychiatric beds for complex individuals View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
William Myers · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William Myers, aged 79, was unlawfully killed; the medical cause of death was multiple stab wounds. The principal concerns related to inconsistent and inappropriate community care of his attacker, including failures to coordinate treatment, recognise warning signs, share relevant information, act on recommendations for Mental Health Act assessment, and maintain adequate records.
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 circulate important clinical risk information to treating clinicians
Wider context from the report “(3) Valuable background information was not circulated to those involved in his treatment with the result that they were deprived of the crucially important medical history of the potential risks (particularly the attacker was no longer taking the medication which controlled his behaviour and was once again resorted to using illicit drugs). An example of this concerns a 20 page discharge report prepared by a Consultant Forensic Psychiatrist at the time the attacker was being prepared to leave Ashworth High Security Hospital. This report not seem to have been material to the Care Coordinator, the GP nor the Consultant Psychiatrist who undertook treatment on two different psychiatric wards and in the community.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake multidisciplinary case conference reassessment by a forensic psychiatrist
Wider context from the report “(2) A variety of incidents should have alerted the clinicians and others involved in his management to the need for a multi-disciplinary case conference reassessment by the Forensic Psychiatrist . Neither of these took place and in consequence warning signs of impending or actual violence were not recognised . Examples include being found by the Police in a public place in possession of a bladed article when under the influence of some illicit substance and admitting he was hearing voices commanding him to kill people.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 continuity of psychiatric care across teams and wards
Wider context from the report “(1) The care and treatment provided to Mr Lound's attacker ('the attacker') in 2015/16 whilst in the community was inconsistent and/or inappropriate management strategy . Instead of being treated by the same team of psychiatric clinicians, he was admitted to four different psychiatric wards during 2015 . The consultants involved in his treatment did not confer sufficiently to produce a clear management plan.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 recommendations to consider Mental Health Act assessment
Wider context from the report “(4) On three occasions during 2015 other clinicians who encountered the attacker recommended that a Mental Health Act assessment be considered with a view to him being detained . These recommendations were not acted upon . Judgements made by Consultant psychiatrists were not acted upon, preferably by a second opinion in the least, but preferably by a Forensic Psychiatrist, as this has been verified by the benefit of hindsight, the attacker's propensity to violent conduct may well have been triggers by a Mental Health Act assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Gaps in clinical record keeping hindering treatment coordination and discharge accountability
Wider context from the report “(5) Gaps in record keeping hindered the coordination of treatment . Examples included a void in the medical notes to explain why the number of letters had been transferred from one psychiatric ward to another (with a different consultant and clinical team), a discharge in his absence (taking place in October 2015) without any record of the assessment having been produced by the same team as to how the risk followed up and why he was to be benefited, nor an explanation as to who had authorised the discharge and the discharge was made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to identify complex cases early and assign them to an appropriately qualified psychiatrist
Wider context from the report “Overall, the lingering concern is complex such as this are not identified early enough and managed by an identified and appropriately qualified psychiatrist . There should be a clear delineation of all the clinicians and agencies involved, by way of periodic case conferences with reasons and decisions made being recorded and circulated. The scarcity of inpatient psychiatric beds fuels the concern that complex individuals are being treated in the community rather than controlling the risks they present by having them remain in hospital until such crimes as their condition has been shown to have stabilised.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 psychiatric consultants to confer sufficiently on a clear management plan
Wider context from the report “(1) The care and treatment provided to Mr Lound's attacker ('the attacker') in 2015/16 whilst in the community was inconsistent and/or inappropriate management strategy. Instead of being treated by the same team of psychiatric clinicians, he was admitted to four different psychiatric wards during 2015. The consultants involved in his treatment did not confer sufficiently to produce a clear management plan .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of inpatient psychiatric beds for complex individuals
Wider context from the report “Overall, the lingering concern is complex such as this are not identified early enough and managed by an identified and appropriately qualified psychiatrist. There should be a clear delineation of all the clinicians and agencies involved, by way of periodic case conferences with reasons and decisions made being recorded and circulated. The scarcity of inpatient psychiatric beds fuels the concern that complex individuals are being treated in the community rather than controlling the risks they present by having them remain in hospital until such crimes as their condition has been shown to have stabilised.
” Open source report
Concerns raised 1 Lack of procedures for reporting anaphylaxis incidents at commercial food premises to Trading Standards 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
Dylan Paul Hill · 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
Dylan Paul Hill died after eating a korma meal containing almond powder contaminated with peanuts at a restaurant in Barnsley, causing an anaphylactic reaction. The report identified concerns about allergen information, ingredient checking and labelling at food premises, and the absence of procedures for reporting non-fatal anaphylactic reactions to Trading Standards and other regulatory authorities.
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 procedures for reporting anaphylaxis incidents at commercial food premises to Trading Standards
Wider context from the report “Evidence was given before the Court of an incident within the same premises in September 2014 where a curry containing nuts was given to a customer who had requested a nut free curry. That customer had an anaphylactic reaction and was taken to hospital where he made a full recovery.
Evidence was also given that the Trading Standards department of the local council had not been told of this incident prior to the death of Mr Hill . Had they known, they would have arranged a priority visit.
After Mr Hill's death the restaurant were issued a prohibition notice that they were not permitted to offer allergen free meals.
Evidence was given that there are no procedures in place for such communications between the health services and Trading Standards in cases of non fatal anaphylactic reactions .
In my opinion there is a risk that future deaths may occur unless cases of non fatal anaphylactic reactions caused by the ingestion of purchases from food business operatives are reported to those regulatory authorities responsible for the supervision and monitoring of food safety and hygiene .
The question therefore arises as to whether the emergency services and health services within the area can work together to ensure that Trading Standards Departments are made aware of all anaphylaxis incidents relating to commercial premises so that the appropriate action can be taken as regards those premises.
” Open source report
Concerns raised 3 Delays in reporting plain radiology within required timescales View source Failure to report non-urgent plain radiology unless specifically requested View source Unfilled consultant radiologist posts 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
Kristina CROSS · 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
Kristina Cross, aged 72, was admitted on 28 August 2016 after an unwitnessed fall and was later found to have a displaced fracture of the neck of the femur. The fracture was initially misdiagnosed, delaying surgical fixation; she subsequently suffered wound complications and joint dislocations, deteriorated after further surgery, and died on 20 November 2016. The principal concerns were unfilled consultant radiologist posts and delays, or failures, in reporting radiological investigations needed for diagnosis and clinical decision-making.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in reporting plain radiology within required timescales
Wider context from the report “Evidence from the Lead Consultant Radiologist of the University Hospitals of Morecambe Bay NHS Foundation Trust was that whilst there was an initial misdiagnosis of the hip fracture there was a subsequent significant delay in reporting on plain radiology , due to a shortage of Consultant Radiologists. Furthermore evidence was heard that non-urgent plain radiology is not being reported at all unless specifically requested by clinicians. Evidence was heard that a quarter of positions within the Trust are currently unfilled. The Dalton Review of July 2014 identified that such is a national position, with comparatively low levels of radiologist training and retention with 41% of unfilled consultant radiological posts remaining unfilled for more than 12 months.
In brief the concerns arising from the evidence are that a substantial number of consultant posts are unfilled, and that due to shortages of qualified radiologists, radiological investigations, crucial for diagnostic and clinical decision making purposes, are not reported on within the timescales set out within Professor Sir Bruce Keogh's report of 2013 , or at all.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to report non-urgent plain radiology unless specifically requested
Wider context from the report “Evidence from the Lead Consultant Radiologist of the University Hospitals of Morecambe Bay NHS Foundation Trust was that whilst there was an initial misdiagnosis of the hip fracture there was a subsequent significant delay in reporting on plain radiology, due to a shortage of Consultant Radiologists. Furthermore evidence was heard that non-urgent plain radiology is not being reported at all unless specifically requested by clinicians . Evidence was heard that a quarter of positions within the Trust are currently unfilled. The Dalton Review of July 2014 identified that such is a national position, with comparatively low levels of radiologist training and retention with 41% of unfilled consultant radiological posts remaining unfilled for more than 12 months.
In brief the concerns arising from the evidence are that a substantial number of consultant posts are unfilled, and that due to shortages of qualified radiologists, radiological investigations, crucial for diagnostic and clinical decision making purposes, are not reported on within the timescales set out within Professor Sir Bruce Keogh's report of 2013, or at all .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unfilled consultant radiologist posts
Wider context from the report “Evidence from the Lead Consultant Radiologist of the University Hospitals of Morecambe Bay NHS Foundation Trust was that whilst there was an initial misdiagnosis of the hip fracture there was a subsequent significant delay in reporting on plain radiology, due to a shortage of Consultant Radiologists. Furthermore evidence was heard that non-urgent plain radiology is not being reported at all unless specifically requested by clinicians. Evidence was heard that a quarter of positions within the Trust are currently unfilled . The Dalton Review of July 2014 identified that such is a national position, with comparatively low levels of radiologist training and retention with 41% of unfilled consultant radiological posts remaining unfilled for more than 12 months.
In brief the concerns arising from the evidence are that a substantial number of consultant posts are unfilled , and that due to shortages of qualified radiologists, radiological investigations, crucial for diagnostic and clinical decision making purposes, are not reported on within the timescales set out within Professor Sir Bruce Keogh's report of 2013, or at all.
” Open source report
18 Dec 2017 Anne Morris · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Failure of the HTT to obtain a written discharge plan from the hospital View source Failure to liaise with the HTT before discharge View source Failure to formulate a written discharge plan identifying the responsible community HTT View source Failure of the HTT to establish the patient's consent to contact a support person View source Failure to identify a responsible HTT for the discharge address View source Failure to inform the relevant HTT of consent to contact support persons View source Failure to contact consented friends and relatives regarding community support View source See 4 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
Anne Morris · 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
Anne Morris died by suicide after hanging herself while alone in a friend’s house on 26 June 2017. The principal concerns were that the Priory Hospital did not contact consented friends or relatives, did not establish a written discharge and follow-up plan, and did not liaise adequately with the relevant Oxleas Home Treatment Team before discharge. Concerns were also raised that the Oxleas team did not obtain a discharge plan or know that Anne had agreed to contact with a friend regarding community support and suicide risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of the HTT to obtain a written discharge plan from the hospital
Wider context from the report “(4) The Oxleas HTT do not appear to have proactively contacted the Priory Hospital for a written discharge plan prior to, or at the time, of the home visit on the 25/6/17. Had the HTT made contact with the Priory Hospital it would still have been possible to formulate a plan (including the availability of collateral assistance from Messrs ████████).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 liaise with the HTT before discharge
Wider context from the report “(3) The Priory Hospital did not identify a responsible HTT for the discharge address in Eltham and there was no liaison with an HTT prior to discharge .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to formulate a written discharge plan identifying the responsible community HTT
Wider context from the report “(2) The Priory Hospital did not formulate a written plan, before discharge from hospital, identifying the HTT who would be responsible for onward care in the community and, in particular making the relevant HTT aware that Anne was agreeable to health care professionals speaking to Peter Forester and Bernard Bakes regarding support with her mental health issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 HTT to establish the patient's consent to contact a support person
Wider context from the report “(5) The Oxleas HTT do not appear to have been aware of Anne’s willingness for mental health professionals to contact her friend ████████ regarding community support with her suicide risk . Had Oxleas HTT proactively made contact with the Priory Hospital they could have been made aware of this arrangement.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to identify a responsible HTT for the discharge address
Wider context from the report “(3) The Priory Hospital did not identify a responsible HTT for the discharge address in Eltham and there was no liaison with an HTT prior to discharge.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the relevant HTT of consent to contact support persons
Wider context from the report “(2) The Priory Hospital did not formulate a written plan, before discharge from hospital, identifying the HTT who would be responsible for onward care in the community and, in particular making the relevant HTT aware that Anne was agreeable to health care professionals speaking to Peter Forester and Bernard Bakes regarding support with her mental health issues .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 contact consented friends and relatives regarding community support
Wider context from the report “(1) I am concerned that the staff at the Priory Hospital did not make contact with friends and relatives after Anne had consented to them being contacted .
” Open source report
28 Nov 2017 Mr Harold Chapman · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Uncertainty in Holter interpretations and identification of NSVTs on traces View source Failure to view, acknowledge and respond to direct-access patient communications View source Lack of checks to ensure review of requested investigations and appropriate action in line with guidelines View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Harold Chapman · 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 Harold Chapman, who had hypertrophic cardiomyopathy, died on 14 June 2016 after developing a significant cardiac arrhythmia. The inquest found that non-sustained ventricular tachycardia identified in 2015 was not reviewed promptly, delaying consideration of an implantable cardioverter defibrillator. A further concern was that patient emails sent to consultants were often not viewed or acted upon, with no response provided.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Uncertainty in Holter interpretations and identification of NSVTs on traces
Wider context from the report “(3) There was also a concern in respect of the holter interpretations and the presence or otherwise of NSVTs on the traces. Barts NHS Trust have instigated a new introduction and training regime for its specialist clinical fellows in the interpretation of holter readings.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 view, acknowledge and respond to direct-access patient communications
Wider context from the report “During the course of the inquest, the evidence revealed during his dealings with the Barts NHS Trust and, more specifically the lead consultants, emails were passed by Mr Chapman to the consultants. It became clear during the inquest that those emails were often not viewed and/or acted upon and as a result no response was received by the patient .
It is fully appreciated that consultants are busy with their clinical responsibilities covering wards, clinics and on-calls.
However, if contact details are provided for ‘direct access’ to individual doctors/consultants, it seems obligatory that those should be viewed, acknowledged and patients responded to .
Patient contact with medical professionals, not just hospital related, is an important part of modern medical practice.
Whilst this is a huge task, it would seem possible to come up with either National or local guidelines in respect of the use of all forms of communication between patients and their clinician (covering phone and emails).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 checks to ensure review of requested investigations and appropriate action in line with guidelines
Wider context from the report “(1) the consultant responsible for Mr Chapman’s care in August and November 2015 was based, at the time, at Barts NHS Trust and is now employed by the Brompton. The consultant was responsible for reviewing the investigations that he (and other members of his team in their absence) had requested.
(2) There appeared to be no check mechanisms in place to ensure that this was done and appropriate action taken in line with the Guidelines..
” 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 Concerns about an individual clinician’s conduct should be referred to the General Medical Council as regulator.
Verbatim wording from the response “I hope this information is helpful and provides assurance that there is guidance available to clinicians in this area. Where there are concerns about the conduct of an individual clinician, these should be brought to the attention of the GMC as regulator.” Source location 2017-0377-Response-by-Department-of-Health
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 GMC and NHS England guidance provides an adequate framework for safe communication with patients and handling test results.
Verbatim wording from the response “I hope this information is helpful and provides assurance that there is guidance available to clinicians in this area. Where there are concerns about the conduct of an individual clinician, these should be brought to the attention of the GMC as regulator.” Source location 2017-0377-Response-by-Department-of-Health
Open published response
Concerns raised 12 Failure of the emergency information-relay system between birthing centres and hospitals View source Failure of midwives to acknowledge and actively consider requests for hospital transfer View source Uncontrolled discretion by call handlers when time-critical factors are disclosed without an explicit time-critical transfer request View source Failure to create CTG equipment accounts for all authorised staff View source Poor technical quality of CTG readings during emergencies View source Vagueness of the Use of Standby Points policy for probing emergency requests View source Unclear classification of urgent, non-urgent and emergency transfers View source Failure of antenatal growth-risk assessment to include maternal BMI and emerging risk factors View source Lack of guidance for midwives on auscultation during transfer to hospital View source Lack of guidance for interpreting fetal heart-rate recovery after a bradycardic episode in labour View source Unavailability of CTG equipment in birthing centres View source Failure to record requests for transfer to hospital in clinical notes View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rafe Robbie Angelo · 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
Rafe Robbie Angelo was born at 17:30 on 23 September 2014 after his mother was transferred from the Blake Birthing Centre to hospital during labour. He was born pale and floppy, without breathing or a heart rate, and died after 37 minutes of resuscitation. The principal concerns included delays in recognising the need for urgent delivery and communication failures between the birthing centre, ambulance service and hospital, including failure to request a time-critical transfer and a non-urgent ambulance stop.
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 the emergency information-relay system between birthing centres and hospitals
Wider context from the report “This was a critical part of this case and as such needs further consideration of both the past and current systems and whether appropriate training has been given; whether it is currently working; and whether refresher training is needed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 midwives to acknowledge and actively consider requests for hospital transfer
Wider context from the report “Although it was found that the notes in this case were very good, nevertheless there was a finding that the mother had made several requests to go to hospital mainly for pain relief during the course of the morning and early afternoon yet none of these requests were recorded in the notes or acknowledged by the midwife . In this case, it was agreed by several witnesses including ████████ that if an earlier transfer had happened this would have led to CTG monitoring and picking up the earlier decelerations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Uncontrolled discretion by call handlers when time-critical factors are disclosed without an explicit time-critical transfer request
Wider context from the report “Discretion of SCAS call handlers if time critical factors are mentioned but birthing centre staff do not actually request a time critical transfer is requested.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 create CTG equipment accounts for all authorised staff
Wider context from the report “Ensuring an account is created for all staff authorised to use CTG equipment so that settings and prints can be run
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 technical quality of CTG readings during emergencies
Wider context from the report “Poor technical quality of the CTG readings at a crucial time especially given this was the first time in an emergency situation
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Vagueness of the Use of Standby Points policy for probing emergency requests
Wider context from the report “The call to SCAS from the Blake lasted 4 minutes, 57 seconds and the fact the baby was in distress was not mentioned until 3 minutes, 53 seconds. The responding ambulance was dispatched at 15:46 and shortly afterwards the paramedic contacted control centre and indicated that it was appreciated the call was an emergency but could they use the facilities first. No questions were asked and permission was given ████████ accepted that if this had been designated as a time critical call, it may have made a difference as to whether permission to use facilities would have been given and asking questions or not would depend on the person taking the call from the paramedic. There was a policy to cover this sort of request – “Use of Standby Points” but it was accepted the policy is very broad and somewhat vague so it was accepted that it would very much depend on the person taking the call to probe further
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unclear classification of urgent, non-urgent and emergency transfers
Wider context from the report “The SIRI investigation highlighted that the instruction given to the maternity support worker was not clear about what category of transfer was required . That is why the maternity service has purchased handsets so that the midwife giving clinical care can contact SCAS directly rather than delegate the task. The request is now made in the birthing room so the mother can hear. In evidence, ████████ indicated that a transfer for epidural would be regarded as an emergency requiring an ambulance within one hour . This was different from ████████ who felt the transfer would be classified as non-urgent . A discussion took place in court as SCAS representatives believed the response times was 30 minutes (para 151).
This needs to be clarified between the Trust and SCAS and then clearly communicated to all 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 of antenatal growth-risk assessment to include maternal BMI and emerging risk factors
Wider context from the report “The risk assessment of Ms Angelo followed NICE guidelines at the time but I remain concerned that no simple weigh check is done to check maternal BMI and that GROW charts only pick up 50-55% of cases where growth restriction occurs. A more holistic view is needed of risk factors especially in last few weeks from 34 weeks onwards as this is when the major growth spurt takes place and monitoring closely when additional factors surface is advisable e.g. as in this case cannabis and anti-depressant use were disclosed during this crucial 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 Lack of guidance for midwives on auscultation during transfer to hospital
Wider context from the report “Guidance for midwives about auscultation practice during transfer to hospital
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for interpreting fetal heart-rate recovery after a bradycardic episode in labour
Wider context from the report “After the bradycardic episode at 11:10 when the maternal position was changed, the recovery rate afterwards was higher than the previous baseline from 130-135 to 150+ thereafter. This was still within “normal” range but it was accepted during the inquest that this could be abnormal and no guidance currently exists .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of CTG equipment in birthing centres
Wider context from the report “CTG is not currently available in birthing centres and should be considered in emergency situations such as this case especially if it is not possible to transport the mother to hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to record requests for transfer to hospital in clinical notes
Wider context from the report “Although it was found that the notes in this case were very good, nevertheless there was a finding that the mother had made several requests to go to hospital mainly for pain relief during the course of the morning and early afternoon yet none of these requests were recorded in the notes or acknowledged by the midwife. In this case, it was agreed by several witnesses including ████████ that if an earlier transfer had happened this would have led to CTG monitoring and picking up the earlier decelerations.
” 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 CTG should not be provided in low-risk birth centres because evidence shows no improved outcomes and increased unnecessary interventions.
Verbatim wording from the response “Birth centres are accessed by women assessed to be low risk for complications. CTG is not made available in birth centres because NICE guidance clearly states that CTG must not be offered to women at low risk of complications in established labour (Intrapartum care for healthy women and babies NICE guidance, CG190, section 1.10.1). There is no evidence that the use of CTG in low-risk women improves the fetal/neonatal outcome. I am further advised that the evidence base shows that CTGs are not recommended in a low-risk population because they have a high false positive rate, generating much unnecessary interventions such as an instrumental delivery or a caesarean section. The evidence suggests that intermittent auscultation in a low-risk population appears to be equally effective at identifying problems but does not cause as much intervention.” Source location 2017-0421-Response-by-Department-of-Health
Open published response
Concerns raised 2 Lack of routine chicken pox vaccination offer for children with Downs Syndrome View source Failure to communicate the increased infection risks associated with Downs Syndrome to parents or carers 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
Tomas Kelly · 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
Tomas Kelly, aged 3, was admitted to hospital after choking and being diagnosed with aspiration pneumonia and a chest infection. After later developing chicken pox, he deteriorated rapidly at home and died in hospital on 22 November 2016; the cause of death was confluent bronchopneumonia. The principal concerns were that his parents may not have been informed about the increased infection risks associated with Down’s Syndrome, and whether children with Down’s Syndrome should routinely be offered chicken pox vaccination.
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 routine chicken pox vaccination offer for children with Downs Syndrome
Wider context from the report “2. Vaccination against chicken pox
a. The evidence confirmed that it is not the chicken pox per se which creates a risk. Rather it is the immunosupppressant effect of this – creating a risk of more serious infections as a result.
b. We heard from a community paediatrician that, as matters stand, there is no plan to vaccinate all children against chicken pox. This is limited to certain high risk groups only.
c. It is clear that children with Downs Syndrome are at increased risk – both of contracting infection and of the infections being more serious.
d. Careful consideration should be given to including children with Downs Syndrome to the category of children who will be routinely offered this vaccination .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the increased infection risks associated with Downs Syndrome to parents or carers
Wider context from the report “1. Talking to parents
a. I did not have concerns about the medical professionals being aware of the increased risks associated with infection in children with Downs Syndrome. I heard no evidence of the parents being made aware of this however – either when he was discharged from hospital on 22 October 2016 or when he was seen by his GP on 21 November 2016.
b. Tomas’ parents said they may have sought additional medical assistance if they had known about these risks.
c. Whilst this may be happening to some extent in community paediatrics, it is important for health professionals in acute settings (including primary care) to be advised to share these risks with parents/ carers, so that they can adopt an appropriate threshold for seeking medical assistance.
” Open source report
17 Nov 2017 Kathryn Verina Richmond · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 1 Failure to stagger ambulance crew shifts and meal breaks 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
Kathryn Verina Richmond · 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
Kathryn Verina Richmond collapsed at home on 21 April 2015, was taken to hospital after delays in ambulance attendance, and died that morning despite lifesaving treatment for a ruptured spleen. The principal concern was that non-staggered ambulance crew shifts led to simultaneous meal breaks, reducing available resources and potentially delaying responses to emergency calls.
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 stagger ambulance crew shifts and meal breaks
Wider context from the report “i. Due to the non-staggering of shift patterns of ambulance crews within Ambulance Service Trusts , there could be increased delays in attending emergency calls due to ambulance staff taking meal breaks at the same time .
” Open source report
Concerns raised 3 Difficulties in accessing appropriate and timely mental health services for patients with known alcohol addiction View source Lack of access to NHS records by out-of-hours services View source Lack of awareness of the complexities of presentations involving known alcohol addiction View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Timothy John Smedley · 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
Timothy John Smedley was found in a shallow waterway at the foot of Rakewood Viaduct on 7 June 2017, and his death was concluded to be suicide. The concerns identified were a lack of joint access to NHS records for out-of-hours services, fragmentation of care, and difficulties for people with alcohol addiction in accessing timely and appropriate mental health services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Difficulties in accessing appropriate and timely mental health services for patients with known alcohol addiction
Wider context from the report “2. The difficulties that patients with known alcohol addiction face in accessing appropriate and timely mental health services , alongside an apparent lack of awareness surrounding the complexities their presentation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 access to NHS records by out-of-hours services
Wider context from the report “1. The lack of (joint) access to NHS records by ‘out of hours’ services such as GPs, Urgent Care Centres etc. resulting in unsafe, fragmentation of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the complexities of presentations involving known alcohol addiction
Wider context from the report “2. The difficulties that patients with known alcohol addiction face in accessing appropriate and timely mental health services, alongside an apparent lack of awareness surrounding the complexities their presentation .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work towards interoperable digital care records across health and care services.
Verbatim wording from the response “We expect that challenges around the sharing of patient information will, in large part, be addressed by the move away from paper records to electronic systems for recording and sharing patient information. Digitisation provides an important opportunity to improve communication flow in the interests of patient safety, leading to improved outcomes and efficiency.” Source location 2017-0398-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £247 million to implement liaison mental health services in emergency departments.
Verbatim wording from the response “In response to this, and through record investment, we are implementing the vision set out in the Five Year Forward View for Mental Health to transform mental health services. This includes investing £400 million to improve crisis care services in the community and £247 million to implement liaison mental health services in emergency departments so that people who present at acute hospitals with mental health problems will be seen by specially trained mental health professionals. Through the Five Year Forward View for Mental Health we are committed to implementing a comprehensive range of community-based mental health pathways of care by 2020.” Source location 2017-0398-Response-by-Department-of-Health
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 Implement comprehensive community-based mental health pathways of care by 2020.
Verbatim wording from the response “In response to this, and through record investment, we are implementing the vision set out in the Five Year Forward View for Mental Health to transform mental health services. This includes investing £400 million to improve crisis care services in the community and £247 million to implement liaison mental health services in emergency departments so that people who present at acute hospitals with mental health problems will be seen by specially trained mental health professionals. Through the Five Year Forward View for Mental Health we are committed to implementing a comprehensive range of community-based mental health pathways of care by 2020.” Source location 2017-0398-Response-by-Department-of-Health
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 Summary Care Record availability and use across more settings, including urgent and emergency care.
Verbatim wording from the response “You may be aware of the introduction of the Summary Care Record which now covers more than 98 percent of the population. The Summary Care Record is being used successfully in many settings across the NHS such as A&E departments, hospital pharmacies, NHS 111, GP out-of-hours services and walk-in centres. Additionally, the Summary Care Record can be seen and used by authorised staff in other areas of the health and care system involved in the patient’s direct care.” Source location 2017-0398-Response-by-Department-of-Health
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 Mental Health Crisis Care Concordat actions and developing and embedding local action plans.
Verbatim wording from the response “We also remain committed to implementing the actions of the national Mental Health Crisis Care Concordat so that no one experiencing a mental health crisis is turned away. Every area has a local Crisis Care Concordat action plan in place and we continue to work with the signatories of the Concordat to ensure these local plans continue to develop and embed within local communities.” Source location 2017-0398-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £400 million to improve community crisis care services.
Verbatim wording from the response “In response to this, and through record investment, we are implementing the vision set out in the Five Year Forward View for Mental Health to transform mental health services. This includes investing £400 million to improve crisis care services in the community and £247 million to implement liaison mental health services in emergency departments so that people who present at acute hospitals with mental health problems will be seen by specially trained mental health professionals. Through the Five Year Forward View for Mental Health we are committed to implementing a comprehensive range of community-based mental health pathways of care by 2020.” Source location 2017-0398-Response-by-Department-of-Health
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 commissioners and providers are responsible for implementing improvements enabling people with co-occurring conditions to access appropriate care and support.
Verbatim wording from the response “It is the responsibility of commissioners and providers to work together at a local level to implement the necessary improvements to ensure this vulnerable group of patients are able to access the high quality care and support to meet their needs. Commissioners are supported through a wide range of planning and assessment processes, payment incentive tools and clinical guidance to develop local solutions.” Source location 2017-0398-Response-by-Department-of-Health
Open published response
Concerns raised 3 Delays in access to Healthy Minds due to long waiting times View source Lack of access to qualified psychological therapy for mental health in-patients View source Lack of access to qualified psychological therapy for patients under the care of the Home Treatment Team View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John Haines · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Haines was admitted to a mental health ward in March 2017 after his anxiety and depression deteriorated, and was discharged on 14 June 2017 with planned follow-up. He was found deceased at home on 17 June 2017 after failing to respond to contact. The report raised concerns about in-patients and Home Treatment Team patients being unable to access qualified psychological therapy, including delays in accessing Healthy Minds.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in access to Healthy Minds due to long waiting times
Wider context from the report “3. Timely access to Healthy Minds is also hindered by long waiting times .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 access to qualified psychological therapy for mental health in-patients
Wider context from the report “1. During the course of the evidence it became apparent that mental health in-patients still do not have access to therapy from a qualified Psychologist , despite the fact that this has been raised in previous Regulation 28 PFD Forms.
Notably, all clinicians were of the professional view that psychological therapy was critical to treatment, alongside psychiatric care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of access to qualified psychological therapy for patients under the care of the Home Treatment Team
Wider context from the report “2. Similarly, patients cannot access a qualified Psychologist whilst under the care of the Home Treatment Team (‘HTT’) etc. The only way for patients to get access to a Psychologist is through referral to ‘Healthy Minds’. Healthy Minds cannot provide access where the patient remains under the care of the HTT etc.
” Open source report
Concerns raised 5 Placement of under-18s in adult crisis houses View source Failure of safe transition of care from CAMHS to Adult Services View source Inadequate out-of-hours mental health provision for 16 to 18 year olds View source Returning under-18s to supported living settings without staff on duty following mental health act assessments View source Failure of communication and information sharing between CAMHS and Adult Services View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Daisy French · 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
Daisy French, who had a history of serious mental health difficulties and was transitioning from child to adult mental health services, died after deliberately placing herself in front of a high-speed train at Meadowhall Railway Station on 19 April 2017. The concerns included communication and information sharing between services, transition of care, differing out-of-hours arrangements for 16- to 18-year-olds, placement of an under-18-year-old in an adult crisis house, and returning her to accommodation without staff on duty after a mental health assessment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Placement of under-18s in adult crisis houses
Wider context from the report “4) Placement of an under 18 year old in a Crisis house for adults
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 safe transition of care from CAMHS to Adult Services
Wider context from the report “2) Transition of care from CAMHS to Adult 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 Inadequate out-of-hours mental health provision for 16 to 18 year olds
Wider context from the report “3) Out of hour’s provision for 16 to 18 years . (During working hours they are considered children and therefore are the responsibility of CAMHS, out of hours the same individuals are considered adults and are therefore assessed by and potentially admitted to adult psychiatric units.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Returning under-18s to supported living settings without staff on duty following mental health act assessments
Wider context from the report “5) Returning an under 18 year old to a supported living setting following a mental health act assessment where no staff are on duty at the premises .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of communication and information sharing between CAMHS and Adult Services
Wider context from the report “1) The communication/information sharing between CAMHS and Adult Services .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue consulting on measures to transform children’s and young people’s mental health services, including improving transition into adult support.
Verbatim wording from the response “Also relevant here is the Transforming Children and Young People’s Mental Health Provision: a Green Paper, published in December 2017 by the Department of Health and the Department for Education, which builds on our commitments through Future in Mind. We are currently consulting on a range of measures to transform children’s and young people’s mental health services, which includes issues such as improving transition for young people who require ongoing mental health support into adulthood.” Source location 2017-0264-Response-by-Department-of-Health
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 Early Intervention in Psychosis services can appropriately accept referrals from young people aged 14 to 18.
Verbatim wording from the response “Your Report states that Daisy was to be transferred from the CAMHS to the local EIT service, which is an adult psychiatric service. My officials have suggested that this refers to the Early Intervention in Psychosis (EIP) service. EIP services can start from age 14 and it is appropriate for young people to be referred to them.” Source location 2017-0264-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local NHS organisations are responsible for reviewing concerns about local mental health services and taking appropriate action.
Verbatim wording from the response “You ask whether it is appropriate for the NHS in Sheffield to review the systems and procedures in place for mental health services for 16 to 18 year olds. Where there are concerns about local health services, it is the responsibility of the local NHS organisations to review those concerns and take action as appropriate. We are clear that learning lessons where things have gone wrong is essential to ensuring the NHS provides safe, high quality care.” Source location 2017-0264-Response-by-Department-of-Health
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 commissioners and providers are responsible for ensuring timely information sharing, communication and joint working between mental health services.
Verbatim wording from the response “Local commissioners and providers are responsible for ensuring processes and systems support the appropriate and timely sharing of information, communication and joint working to meet the needs of people who require support. This includes mental health services.” Source location 2017-0264-Response-by-Department-of-Health
Open published response
6 Nov 2017 RYAN JAMES VOUT · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Inability to pre-arrange ambulance attendance during execution of a s.135 (1) MHA Act 1983 warrant View source Failure to inform family before discharge View source Failure of hospital and community professionals to liaise before discharge View source Lack of a formal briefing or risk assessment before entry under a s.135 (1) MHA Act 1983 warrant 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
RYAN JAMES VOUT · 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
Ryan James Vout, who had paranoid schizophrenia and was apparently unmedicated, stabbed himself in the chest during an attempt by police officers to execute a section 135 warrant on 10 August 2016. He died despite emergency first aid and hospital treatment. The principal concerns were inadequate coordination before his discharge from psychiatric care, the inability to pre-arrange an ambulance for section 135 warrant attendances, and the lack of a formal briefing or risk assessment before officers entered the premises.
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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 Inability to pre-arrange ambulance attendance during execution of a s.135 (1) MHA Act 1983 warrant
Wider context from the report “(2) The inability to pre-arrange attendance of an ambulance when police officers exercise a s.135 (1) MHA Act 1983 warrant;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to inform family before discharge
Wider context from the report “(1) The lack of a co-ordinated discharge from in-patient psychiatric care into the community, in particular the failure of appropriate professionals from hospital and community to liaise and for family to be informed as a pre-requisite for discharge ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital and community professionals to liaise before discharge
Wider context from the report “(1) The lack of a co-ordinated discharge from in-patient psychiatric care into the community, in particular the failure of appropriate professionals from hospital and community to liaise and for family to be informed as a pre-requisite for discharge;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal briefing or risk assessment before entry under a s.135 (1) MHA Act 1983 warrant
Wider context from the report “(3) The lack of a formality to the ‘briefing’ or risk assessment exercise before officers enter premises with a view to exercising a s.135 (1) MHA Act 1983 warrant.
” 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 local areas to embed and improve their Mental Health Crisis Care Concordat action plans.
Verbatim wording from the response “You may also be aware that we launched the Mental Health Crisis Care Concordat in 2014 which has been signed by all services, including the police service and the NHS, involved in providing care for people who may experience a mental health crisis. The Crisis Care Concordat is clear that every local area should have agreed clear protocols for local services responding to a mental health crisis which clearly identify roles and responsibilities. Every local area has a Mental Health Crisis Care Concordat Action Plan in place and we continue to work with these areas to embed and improve their plans.” Source location 2017-0376-Response-by-Department-of-Health
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 Launch the Mental Health Crisis Care Concordat establishing agreed protocols for local mental health crisis responses.
Verbatim wording from the response “You may also be aware that we launched the Mental Health Crisis Care Concordat in 2014 which has been signed by all services, including the police service and the NHS, involved in providing care for people who may experience a mental health crisis. The Crisis Care Concordat is clear that every local area should have agreed clear protocols for local services responding to a mental health crisis which clearly identify roles and responsibilities. Every local area has a Mental Health Crisis Care Concordat Action Plan in place and we continue to work with these areas to embed and improve their plans.” Source location 2017-0376-Response-by-Department-of-Health
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 Revise the Mental Health Act Code of Practice to set guiding principles for improving patient care.
Verbatim wording from the response “The Mental Health Act 1983 Code of Practice, whilst being statutory guidance for providers of services under the Act, should be observed as best practice by all commissioners and providers of services to people who may become subject to the Act. We revised the Code of Practice in 2015 and set out guiding principles to improve the care for patients. The principles include mental health providers involving patients’ carers and families in decisions about their care. The Code of Practice also makes it clear that we expect multi-disciplinary teams involved in care planning and discharge to include all relevant professionals and agencies which may be involved in a person’s care.” Source location 2017-0376-Response-by-Department-of-Health
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 Operational discharge and conveyance arrangements are matters for local health services, commissioners, providers, ambulance services and police.
Verbatim wording from the response “The other two areas of concern fall to health services. The matters raised are operational and relate to the Nottinghamshire Healthcare NHS Foundation Trust and the ambulance service and I trust the responses you will receive from those organisations will be helpful. My response will focus on the national policy expectations in relation to the issues you have raised.” Source location 2017-0376-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police risk assessment before executing a section 135 warrant is outside the respondent’s remit and will not be addressed.
Verbatim wording from the response “Your report raises three areas of concern. Firstly, around discharge planning; secondly, the ability to pre-book appropriate transport for conveyance of a patient being sectioned under the Mental Health Act; and thirdly, the risk assessment conducted by the police prior to the exercise of a section 135 warrant.” Source location 2017-0376-Response-by-Department-of-Health
Open published response
Concerns raised 1 Easy online access to large amounts of medication, including prescription-only drugs 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
Jane Allison Powell · 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
Jane Allison Powell was found deceased at home on 6 December 2016 after last being seen alive between 25 and 28 November 2016. The probable cause of death was multiple drug toxicity, and the report raised concern about the ease of obtaining large amounts of medication, including prescription-only drugs, over the internet and the risk of future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Easy online access to large amounts of medication, including prescription-only drugs
Wider context from the report “1. The evidence in this case demonstrated how easy it is for individuals to obtain large amounts of medication (including those normally deemed to be ‘prescription only’ drugs) over the internet . Whilst this problem has already been recognised by the pharmaceutical profession and its regulatory body, it is unclear what action has been/is being taken in order to address the situation.
My concern is that, if left, there is a significant risk of future deaths.
” Open source report
Concerns raised 3 Failure to provide nursing staff with instructions on the operational integrity of essential falls-risk equipment View source Unsuitability of wireless WiFi activation when several fall mats are in proximity View source Unreliability of Rambledguard fall mats for their intended purpose 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
Pauline Hayston · 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
Pauline Hayston, who had reduced mobility, frailty and recent falls, sustained an unwitnessed fall while attempting to mobilise as an inpatient and later died following a fractured neck of femur and resulting immobility. The concerns identified related to the reliability and fitness for purpose of the Rambledguard falls mats, the suitability of the wireless system when several mats were in use, and the absence of technical instructions for nursing staff about operational problems.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide nursing staff with instructions on the operational integrity of essential falls-risk equipment
Wider context from the report “The evidence raises the following concerns:
1. The reliability of the Rambledguard fall mats and its fitness for purpose.
2. The suitability of a wireless “WiFi” activated where several fall mats are in place in proximity to each other.
3. Insertion of instructions to nursing staff where the operational integrity of an essential equipment to alleviate falls risks has been identified.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unsuitability of wireless WiFi activation when several fall mats are in proximity
Wider context from the report “The evidence raises the following concerns:
1. The reliability of the Rambledguard fall mats and its fitness for purpose.
2. The suitability of a wireless “WiFi” activated where several fall mats are in place in proximity to each other.
3. Insertion of instructions to nursing staff where the operational integrity of an essential equipment to alleviate falls risks has been identified.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unreliability of Rambledguard fall mats for their intended purpose
Wider context from the report “The evidence raises the following concerns:
1. The reliability of the Rambledguard fall mats and its fitness for purpose.
2. The suitability of a wireless “WiFi” activated where several fall mats are in place in proximity to each other.
3. Insertion of instructions to nursing staff where the operational integrity of an essential equipment to alleviate falls risks has been identified.
” 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 Wi-Fi is not involved in the fall mats’ processes and therefore cannot cause delays or cross-talk with other devices.
Verbatim wording from the response “Firstly, I understand from Bolton NHS Foundation Trust that it has worked closely with Ramblegard Ltd to explore your concerns. I am advised that there is no issue in regard to Wi-Fi potentially causing a delay, or ‘cross-talking’, with other devices, as Wi-Fi is not involved in the processes.” Source location 2017-0278-Response-by-Department-of-Health
Open published response
28 Sep 2017 GILLIAN O’KEEFFE · Prevention of Future Deaths report London Inner (West)
View report summary
Concerns raised 5 Unlikelihood of self-referral by patients unable to engage with mental health services View source Inappropriate discharge of patients in greatest need of mental health support for non-engagement View source Failure to coordinate pre-discharge handover and transition with the GP surgery View source Lack of an accessible mechanism for families to share mental health concerns with the professional team View source Lack of a procedure for following up urgent GP concerns or referrals 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
GILLIAN O’KEEFFE · 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
Gillian O’Keeffe had a serious mental illness and died at home on 19 March 2017 after taking her own life while the balance of her mind was disturbed. The concerns included her discharge from community mental health services for non-engagement despite family and professional concerns, inadequate communication with her GP and family, and the absence of a clear process for following up urgent concerns or referrals.
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 Unlikelihood of self-referral by patients unable to engage with mental health services
Wider context from the report “(2) In view of her history and the inability of the Trust or GP surgery to make contact with Mrs O’Keeffe it was highly unlikely that she would self-refer .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 discharge of patients in greatest need of mental health support for non-engagement
Wider context from the report “(1) That the decision to discharge Mrs O’Keeffe ‘for non-engagement’ from the local Mental Health NHS Foundation Trust care in January 2017 appeared illogical when it was likely, having regard to the facts, that she was in greatest need of their help : she was a service user of long standing, she had an acute deterioration in her mental state in March 2016, that there had been concerns raised by her family in October 2016 and that no professionals had been able to make visual contact with her since October 2016.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 coordinate pre-discharge handover and transition with the GP surgery
Wider context from the report “(3) There was no pre-discharge multidisciplinary meeting to include and inform the GP before discharge nor attempt to ensure that there was a seamless transition to the GP surgery .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of an accessible mechanism for families to share mental health concerns with the professional team
Wider context from the report “(5) There appeared no easy or appropriate way that the family were able to share information and their concerns about Mrs O’Keeffe’s mental health with the professional team , consequently, notwithstanding the family’s continual and concerted attempts to notify Mrs O’Keeffe’s care co-ordinator, they felt that the professionals were unaware of the parlous state of Mrs O’Keeffe’s mental health and the family’s serious 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 a procedure for following up urgent GP concerns or referrals
Wider context from the report “(4) Evidence was given at the inquest that there was no procedure or policy in place at the Trust to follow up GP concerns or referrals particularly where there was likely to be a degree of urgency .
” Open source report
Concerns raised 1 Lack of long-term mental health care for children unable to attend hospital because of anxiety View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brandon Singh Rayat · 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
Brandon Singh Rayat, aged 15, died in hospital on 10 August 2016 after being discovered hanging at home the previous day. The report identified a concern that there was no provision of long-term mental health care for children in Leicestershire whose anxiety prevented them from attending hospital for treatment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of long-term mental health care for children unable to attend hospital because of anxiety
Wider context from the report “That there is no provision of mental health care for children in Leicestershire who due to their anxiety are unable to attend hospital for treatment . There is a CRISIS team for children but I have been told that this cannot fulfil the function of long term treatment .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local health-service provision, including children’s mental-health services, is for local commissioners and authorities to determine.
Verbatim wording from the response “The provision of local health services is a matter for local determination. However, I can explain the work we are undertaking to transform children and young people’s mental health and improve access to high quality services for all children and young people that need them. We are working with partners across the system to embed these principles so that commissioners from across health, social care and education are able to build an improved local support offer.” Source location 2017-0231-Response-by-Department-of-Health
Open published response
4 Sep 2017 Anthony William McCormack · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 4 Failure of ambulance services to meet nationally set emergency response-time targets View source Inadequate training of airline staff to recognise cardiac arrest and administer first aid or prompt CPR View source Inadequate procedures for responding when the Tempus system is unable to provide assistance View source Insufficient paramedic staffing to provide Advanced Life Support at Manchester Airport 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
Anthony William McCormack · 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
Anthony William McCormack became unwell and collapsed while an aircraft was taxiing at Manchester Airport, later suffering cardiac arrest and dying after resuscitation attempts at Wythenshawe Hospital. The report identified concerns about Emirates staff recognising cardiac arrest and agonal breathing, starting CPR promptly, and procedures when the Tempus system could not provide assistance. It also raised concerns about ambulance response targets and the availability of only one paramedic at Manchester Airport.
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 ambulance services to meet nationally set emergency response-time targets
Wider context from the report “• I heard evidence that NWAS failed to meet target times which are nationally set by the Department of Health and that although NWAS was given more financial resources in November 2015 (for provision of more ambulances and recruitment of an additional 400 staff) I was also informed since April 2017 none of the nationally set targets have been met by any ambulance trust in England and Wales namely, a Red 1 response within 8 minutes 75% of the time, Red 2 within 19 minutes 95% of the time, I was also informed that there has been a massive increase of calls to 999 with consequent impact on response times and delays in ambulance turnaround at hospitals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of airline staff to recognise cardiac arrest and administer first aid or prompt CPR
Wider context from the report “• The adequacy of the training of Emirates staff in respect of the recognition of possible cardiac arrest and signs thereof including agonal breathing and the administration of appropriate first aid/prompt CPR
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate procedures for responding when the Tempus system is unable to provide assistance
Wider context from the report “• The adequacy and effectiveness of the procedures followed by Emirates staff in the event that the Tempus system is unable to provide assistance which was the case here.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 paramedic staffing to provide Advanced Life Support at Manchester Airport
Wider context from the report “• Consequent on the above and in this specific case there was only one paramedic on duty at any one time for the Manchester Airport . Such paramedic being required to carry out Basic Life Support alone and unable to start Advanced Life Support .
” 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 Improve ambulance-trust productivity and efficiency through the ambulance improvement programme.
Verbatim wording from the response “The Department continues to work closely with NHS England and NHS Improvement to monitor and support performance in 2017-18, and there is a range of ambulance improvement programme work underway. This includes work to improve the clinical capability and conditions for paramedics; commissioning and operating models for ambulance services; and ambulance trust productivity and efficiency.” Source location 2017-0241-Response-by-Department-of-Health
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 Agree to implement an improved ambulance performance framework with national response standards and prioritised responses for the sickest patients.
Verbatim wording from the response “I would like to take this opportunity to highlight that, following an independent evaluation of extensive trials, we have agreed NHS England’s recommendation to implement an improved ambulance performance framework, which:” Source location 2017-0241-Response-by-Department-of-Health
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 Improve clinical capability and working conditions for ambulance paramedics through the ambulance improvement programme.
Verbatim wording from the response “The Department continues to work closely with NHS England and NHS Improvement to monitor and support performance in 2017-18, and there is a range of ambulance improvement programme work underway. This includes work to improve the clinical capability and conditions for paramedics; commissioning and operating models for ambulance services; and ambulance trust productivity and efficiency.” Source location 2017-0241-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The North West Ambulance Service and its commissioners consider one airport paramedic adequate for current activity, with a second reviewed as expansion occurs.
Verbatim wording from the response “Finally, as you will know, Manchester Airport is expanding. I am advised that work is underway to understand the impact this will have on the North West Ambulance Service and whether or not a second paramedic at Manchester Airport is required. This will be reviewed as the expansion takes place, but I am advised by” Source location 2017-0241-Response-by-Department-of-Health
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 Provision of emergency ambulance services is assigned to the local NHS, including the North West Ambulance Service and its commissioners.
Verbatim wording from the response “I should explain that the provision of emergency ambulance services is a matter for the local NHS. My officials have made enquiries with the North West Ambulance Service NHS Trust and the NHS Blackpool Clinical Commissioning Group (CCG), as lead commissioner for ambulance services in the North West region.” Source location 2017-0241-Response-by-Department-of-Health
Open published response
Concerns raised 3 Failure to ensure understanding of the meaning of countersigning risk assessment checklists View source Failure to seek medical or paramedic assistance when warranted by a person's condition View source Failure to address inaccuracies in moving and handling risk assessment checklists during investigations 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
Helen Theresa Cannon · 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
Helen Theresa Cannon fell at home on 2 April 2017 and was assisted from the floor by Eldercare emergency responders without medical or paramedic assistance being sought. She had suffered internal haemorrhage from a pelvic fracture sustained in the fall and died two days later; concerns were also identified about inaccuracies in the moving and handling risk assessment and flaws in Eldercare’s subsequent investigation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure understanding of the meaning of countersigning risk assessment checklists
Wider context from the report “2. Following Mrs Cannon’s death Eldercare carried out an investigation. The investigation was flawed in that it did not address clear inaccuracies in the Moving and Handling Risk assessment checklist completed by one of the Emergency Responders, nor did it discover that the other Emergency Responder attending did not understand that he was agreeing with the accuracy of the information recorded on the checklist when he countersigned it . It was his belief that he signed the checklist simply to agree that he had been present .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to seek medical or paramedic assistance when warranted by a person's condition
Wider context from the report “1. The emergency responders did not seek medical or paramedic assistance for Mrs Cannon because she was complaining of suffering aching rather than pain . It transpired that Mrs Cannon had suffered internal haemorrhage as a result of a pelvic fracture sustained in her fall, and this led to her death two days later. Evidence was heard at the Inquest from a Consultant Trauma and Orthopaedic Surgeon that in the circumstances it would have been good practice to have obtained medical or paramedic assistance for Mrs Cannon .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 address inaccuracies in moving and handling risk assessment checklists during investigations
Wider context from the report “2. Following Mrs Cannon’s death Eldercare carried out an investigation. The investigation was flawed in that it did not address clear inaccuracies in the Moving and Handling Risk assessment checklist completed by one of the Emergency Responders, nor did it discover that the other Emergency Responder attending did not understand that he was agreeing with the accuracy of the information recorded on the checklist when he countersigned it. It was his belief that he signed the checklist simply to agree that he had been present.
” Open source report
Concerns raised 7 Shortage of General Practitioners caused by recruitment and retention problems View source Inadequate duration and breadth of GP training View source Increased referral and treatment thresholds restricting access to specialist autism and ADHD/ADD services View source Inadequate duration of GP appointments View source Lack of continuity of care caused by reliance on locum GPs View source Failure of general practice access systems to provide appropriate doctor consultations View source Delays and unavailability in access to GP appointments View source See 4 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
Christopher Ian Fairhurst · 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
Christopher Ian Fairhurst, aged 26, was found deceased on a footpath near Spotland Bridge, Rochdale, on 5 December 2016, with empty alcohol bottles and paracetamol packets nearby. The report identified concerns about shortages of GPs, lack of continuity and accessibility of care, inadequate appointment times and GP training, and increasing demand and referral thresholds for adult and children’s Autism and ADHD/ADD services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Shortage of General Practitioners caused by recruitment and retention problems
Wider context from the report “1. There is a shortage of General Practitioners (GPs) as a result of recruitment and retention problems. Surgeries are working with only 50% (or less) of their required establishment. This puts patients at risk and places unmanageable workloads upon those GPs who are in post.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate duration and breadth of GP training
Wider context from the report “5. GP training - GP trainees currently undertake a 3 year training programme. The overall view of the profession is that this is inadequate and ought to be no less than 5 years in order to ensure safe standards of care in general practice . By virtue of their role, GPs require high calibre, ‘across the board’ training in a significant number of specialities . The concept of a 5-year training programme is supported by the Royal College of GPs. Whilst I recognise that a longer training programme may result in a short term reduction in the number of doctors qualified/available for appointment, in the longer term doctors will be better qualified and more able to care for patients with increasingly complex health needs/problems.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Increased referral and treatment thresholds restricting access to specialist autism and ADHD/ADD services
Wider context from the report “6. Both adult and children’s Autism and ADHD/ADD Psychiatric and Psychology services are currently struggling to cope with increasing demand for this area of mental health/neurodevelopmental care provision. The ‘threshold’ for referral and/or treatment has therefore been intentionally increased in order to try and address the problem. I am concerned that this is unsafe. It reduces patient accessibility to specialist diagnosis, care and treatment and places further burden upon GPs to care for patients with complex conditions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate duration of GP appointments
Wider context from the report “3. In order to meet ever increasing demand and to reduce delays in accessibility, GPs are being forced to adopt alternative systems such as telephone consultations (upwards of 50 per day; this is over and above all other aspects of their job) rather than face to face appointments, offering patients appointments with other health care professionals rather than a doctor etc. Further, the average appointment with a doctor – where an appointment is secured – has decreased as a direct consequence of demand and is currently an average of 7.5 minutes per patient . This is insufficient in most cases and wholly inadequate in others e.g. where the patient has a complex medical history or mental health problems. Offering double or treble appointments does not solve this problem as it reduces the number of appointments available for others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of continuity of care caused by reliance on locum GPs
Wider context from the report “2. As a consequence of 1 above, many surgeries are heavily reliant upon locum GPs . For patients this brings about a lack of continuity of care , putting patient safety at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of general practice access systems to provide appropriate doctor consultations
Wider context from the report “3. In order to meet ever increasing demand and to reduce delays in accessibility, GPs are being forced to adopt alternative systems such as telephone consultations (upwards of 50 per day; this is over and above all other aspects of their job) rather than face to face appointments , offering patients appointments with other health care professionals rather than a doctor etc. Further, the average appointment with a doctor – where an appointment is secured – has decreased as a direct consequence of demand and is currently an average of 7.5 minutes per patient. This is insufficient in most cases and wholly inadequate in others e.g. where the patient has a complex medical history or mental health problems. Offering double or treble appointments does not solve this problem as it reduces the number of appointments available for others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays and unavailability in access to GP appointments
Wider context from the report “4. Patients frequently find themselves held in long telephone queues when trying to get appointments . When they eventually get through (often after half an hour or so of waiting), they are told that all appointments for that day have already gone . When they ring the following day, the situation is repeated. Patients often give up or spend days trying before they eventually get a GP appointment . At peak times (Monday/Friday mornings) surgeries can have as many as 300 incoming calls first thing.
” Open source report
8 Aug 2017 Deidre Harvey · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 9 Lack of effective tracking of items taken from and returned to patients View source Lack of routine clinical monitoring of Hydroxychloroquine levels View source Lack of active input from outside consultants into mental health unit patient care View source Failure of liaison between dermatologists and other consultants about Hydroxychloroquine toxicity View source Lack of awareness of Hydroxychloroquine toxic accumulation at recommended doses View source Delays in rectifying obvious ligature points on mental health units View source Incomplete description of the risk of combining Lamotrigine or similar drugs with Hydroxychloroquine View source Lack of awareness among psychiatrists of Hydroxychloroquine mental and toxic side-effects View source Failure to disseminate risk management policies clearly to frontline staff View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Deidre Harvey · 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
Deidre Harvey died on 19 April 2017 after attaching a dressing gown cord to her neck in a mental health unit bathroom; the cause of death was recorded as hanging. The report raised concerns about coordination between mental-health and outside consultants, management of ligature risks and dangerous items, risk-assessment communication, and the potential toxicity and monitoring of hydroxychloroquine.
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 effective tracking of items taken from and returned to patients
Wider context from the report “Secretary of State for Health
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Minister for Health, Welsh Assembly Government
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Chief Executive – Cwm Taf University Health Board
1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when.
The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient.
2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised.
The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion
Editor British National Formulary
Hydroxychloroquine
1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic.
The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine.
Royal College of Psychiatrists
Hydroxychloroquine
1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis.
The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects.
In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition
British Association of Dermatologists
Hydroxychloroquine
1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L.
The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose.
The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared.
CEO Alerts NHS
Hydroxychloroquine
1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important.
The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 routine clinical monitoring of Hydroxychloroquine levels
Wider context from the report “Secretary of State for Health
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Minister for Health, Welsh Assembly Government
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Chief Executive – Cwm Taf University Health Board
1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when.
The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient.
2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised.
The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion
Editor British National Formulary
Hydroxychloroquine
1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic.
The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine.
Royal College of Psychiatrists
Hydroxychloroquine
1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis.
The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects.
In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition
British Association of Dermatologists
Hydroxychloroquine
1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L.
The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose.
The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared.
CEO Alerts NHS
Hydroxychloroquine
1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important.
The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 active input from outside consultants into mental health unit patient care
Wider context from the report “Secretary of State for Health
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Minister for Health, Welsh Assembly Government
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Chief Executive – Cwm Taf University Health Board
1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when.
The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient.
2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised.
The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion
Editor British National Formulary
Hydroxychloroquine
1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic.
The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine.
Royal College of Psychiatrists
Hydroxychloroquine
1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis.
The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects.
In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition
British Association of Dermatologists
Hydroxychloroquine
1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L.
The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose.
The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared.
CEO Alerts NHS
Hydroxychloroquine
1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important.
The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 liaison between dermatologists and other consultants about Hydroxychloroquine toxicity
Wider context from the report “Secretary of State for Health
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Minister for Health, Welsh Assembly Government
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Chief Executive – Cwm Taf University Health Board
1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when.
The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient.
2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised.
The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion
Editor British National Formulary
Hydroxychloroquine
1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic.
The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine.
Royal College of Psychiatrists
Hydroxychloroquine
1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis.
The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects.
In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition
British Association of Dermatologists
Hydroxychloroquine
1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L.
The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose.
The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared.
CEO Alerts NHS
Hydroxychloroquine
1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important.
The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of Hydroxychloroquine toxic accumulation at recommended doses
Wider context from the report “Secretary of State for Health
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Minister for Health, Welsh Assembly Government
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Chief Executive – Cwm Taf University Health Board
1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when.
The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient.
2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised.
The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion
Editor British National Formulary
Hydroxychloroquine
1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic.
The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine.
Royal College of Psychiatrists
Hydroxychloroquine
1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis.
The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects.
In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition
British Association of Dermatologists
Hydroxychloroquine
1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L.
The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose.
The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared.
CEO Alerts NHS
Hydroxychloroquine
1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important.
The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 rectifying obvious ligature points on mental health units
Wider context from the report “Secretary of State for Health
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Minister for Health, Welsh Assembly Government
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Chief Executive – Cwm Taf University Health Board
1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when.
The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient.
2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised.
The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion
Editor British National Formulary
Hydroxychloroquine
1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic.
The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine.
Royal College of Psychiatrists
Hydroxychloroquine
1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis.
The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects.
In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition
British Association of Dermatologists
Hydroxychloroquine
1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L.
The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose.
The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared.
CEO Alerts NHS
Hydroxychloroquine
1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important.
The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Incomplete description of the risk of combining Lamotrigine or similar drugs with Hydroxychloroquine
Wider context from the report “Secretary of State for Health
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Minister for Health, Welsh Assembly Government
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Chief Executive – Cwm Taf University Health Board
1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when.
The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient.
2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised.
The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion
Editor British National Formulary
Hydroxychloroquine
1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic.
The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine.
Royal College of Psychiatrists
Hydroxychloroquine
1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis.
The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects.
In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition
British Association of Dermatologists
Hydroxychloroquine
1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L.
The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose.
The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared.
CEO Alerts NHS
Hydroxychloroquine
1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important.
The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among psychiatrists of Hydroxychloroquine mental and toxic side-effects
Wider context from the report “Secretary of State for Health
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Minister for Health, Welsh Assembly Government
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Chief Executive – Cwm Taf University Health Board
1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when.
The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient.
2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised.
The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion
Editor British National Formulary
Hydroxychloroquine
1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic.
The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine.
Royal College of Psychiatrists
Hydroxychloroquine
1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis.
The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects.
In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition
British Association of Dermatologists
Hydroxychloroquine
1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L.
The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose.
The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared.
CEO Alerts NHS
Hydroxychloroquine
1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important.
The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate risk management policies clearly to frontline staff
Wider context from the report “Secretary of State for Health
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Minister for Health, Welsh Assembly Government
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Chief Executive – Cwm Taf University Health Board
1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when.
The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient.
2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised.
The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion
Editor British National Formulary
Hydroxychloroquine
1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic.
The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine.
Royal College of Psychiatrists
Hydroxychloroquine
1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis.
The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects.
In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition
British Association of Dermatologists
Hydroxychloroquine
1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L.
The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose.
The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared.
CEO Alerts NHS
Hydroxychloroquine
1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important.
The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers.
” 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 Mental health providers in England are responsible for assessing and managing environmental ligature risks under their policies and available guidance.
Verbatim wording from the response “Turning to your second matter of concern, on the removal of ligature points in mental health settings, it is for mental health providers in England to ensure they have policies in place to effectively assess and manage environmental risk in line with available guidance⁴⁵.” Source location 2018-0266-Response-by-Department-of-Health-Social-Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for NHS matters in Wales is devolved and falls outside the scope of this England policy response.
Verbatim wording from the response “Your report directs two matters of concern to the Secretary of State for Health which I will address in turn giving the policy position in England. You will appreciate that responsibility for the NHS in Wales is a devolved matter.” Source location 2018-0266-Response-by-Department-of-Health-Social-Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation MHRA and NHS Improvement are responding separately to concerns about monitoring patients prescribed hydroxychloroquine.
Verbatim wording from the response “Finally, I am aware that the MHRA and NHS Improvement are responding separately to your matter of concern on the monitoring of patients who are prescribed Hydroxychloroquine. I hope that response is helpful.” Source location 2018-0266-Response-by-Department-of-Health-Social-Care
Open published response
21 Jul 2017 Pauline Taylor · Prevention of Future Deaths report West Yorkshire (West)
View report summary
Concerns raised 9 Potential fire hazard from low-paraffin emollient creams View source Failure to verbally inform over-the-counter purchasers of fire hazards from low-paraffin emollient creams View source Fire escalation hazard from polyurethane coating on Nimbus 6 airflow mattress coverings View source Failure to provide private community-care companies with alerts about relevant medicines and medical devices View source Failure to offer a further fire-risk-assessment referral or review after a major change in circumstances View source Lack of healthcare professional awareness of fire hazards from low-paraffin emollient creams View source Lack of care-home awareness of fire hazards from low-paraffin emollient creams View source Failure to display fire-risk warnings on all product packaging View source Failure to undertake a further risk assessment after a significant change in circumstances View source See 6 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
Pauline 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
Pauline Taylor, who was bedbound and living alone, died in her home after a fire developed around her bed on 30 May 2015. The report identified concerns about the fire risks of low-paraffin emollient creams, limited warnings and awareness of those risks, the contribution of the airflow mattress, and the absence of a further risk assessment after her circumstances changed.
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 Potential fire hazard from low-paraffin emollient creams
Wider context from the report “(1) Zerobase and other emollient creams which contain a low level of paraffin pose a potential fire hazard risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to verbally inform over-the-counter purchasers of fire hazards from low-paraffin emollient creams
Wider context from the report “(4) Members of the public are able to purchase emollient creams across the counter but are not verbally made aware of the potential fire hazards of emollient cream containing a low level of paraffin .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Fire escalation hazard from polyurethane coating on Nimbus 6 airflow mattress coverings
Wider context from the report “(7) The polyurethane coating used in the outer covering of the nimbus 6 airflow mattress appears to have contributed to the speed of the fires development and also its intensity.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 private community-care companies with alerts about relevant medicines and medical devices
Wider context from the report “(5) Private companies who provide carers in the community do not receive alerts with regard to medicines and medical devices which could impact on the risk assessments and the manner in which carers working in the private sector provide care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to offer a further fire-risk-assessment referral or review after a major change in circumstances
Wider context from the report “(9) A further fire risk assessment referral/review was not offered to Mrs Taylor by Locala following a major change in her circumstance (she had become bedbound in March 2017.)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 healthcare professional awareness of fire hazards from low-paraffin emollient creams
Wider context from the report “(3) Health care professionals both in a hospital and community setting may not be aware of the potential fire hazard posed by emollient creams which contain a low level of paraffin.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of care-home awareness of fire hazards from low-paraffin emollient creams
Wider context from the report “(6) Care homes (in both the local authority and private sector) who provide residential/nursing care may not be aware of the potential fire hazard risk of emollient creams which contain low levels of paraffin.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 display fire-risk warnings on all product packaging
Wider context from the report “(2) Warnings of such risks are not displayed on all product packaging.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 a further risk assessment after a significant change in circumstances
Wider context from the report “(8) Following a significant change in Mrs Taylor's circumstances in March 2015 a further risk assessment had not been undertaken by Locala.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations