Concerns raised 3 Lack of refresher training in patient feeding techniques and associated risks View source Lack of patient feeding training for family members and other close carers View source Lack of comprehensive staff training in patient feeding techniques and associated risks 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
Margaret Rogerson · 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
Margaret Rogerson, known as Peggy, died at Victoria House, Mill View Care Home, Bolton, from asphyxia due to aspiration of pureed food while being fed. The report raised concerns about a care assistant’s inability to recall training on feeding techniques and risks, the absence of refresher training, and the lack of training available to family members and others close to patients.
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 refresher training in patient feeding techniques and associated risks
Wider context from the report “2. There was no evidence of there being any refresher training in the above matters .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 patient feeding training for family members and other close carers
Wider context from the report “3. There was no evidence of there being any training available to family members and others close to patients in the above matters . There was clear and striking evidence that family members and others would appreciate such training being available to them because in patients with advanced dementia feeding was often the only communication available between patients and their loved ones. There was also evidence that being able to do this in a professional and safe manner would be a great comfort to patient’s relatives and loved ones, who would as a result feel that they themselves were doing something meaningful for the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 comprehensive staff training in patient feeding techniques and associated risks
Wider context from the report “1. A Care Assistant giving evidence at the Inquest could not recall having been trained in the mechanisms of and techniques of how to feed a patient . Particularly there was no evidence of any training relating to the risks involved in feeding patients nor as to the risks created by particular conditions from which patients were suffering .
” Open source report
20 Apr 2016 Helen Elizabeth Patton · Prevention of Future Deaths report Newcastle upon Tyne
View report summary
Concerns raised 3 Failure to undertake Mini Tracheostomy Procedures with ultrasound guidance or in theatre conditions View source Lack of national guidance for Mini Tracheostomy Procedures View source Risk of mortality from Mini Tracheostomy Procedures undertaken without theatre conditions or ultrasound guidance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Helen Elizabeth Patton · 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 Elizabeth Patton developed infection, respiratory failure and a fast heart rhythm after a right lobectomy, and underwent a mini tracheostomy to remove secretions. During the procedure, performed on an intensive care ward without ultrasound guidance, a small thyroid artery was damaged, causing catastrophic bleeding and her death; concerns were raised about the continuing risk of mortality and the absence of national guidance for such procedures.
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 undertake Mini Tracheostomy Procedures with ultrasound guidance or in theatre conditions
Wider context from the report “(1) The Continuing risk of mortality where Mini Tracheostomy Procedures are not undertaken within theatre conditions or ultrasound guided
(2) That Mini Tracheostomy Procedures are undertaken regularly on a national level without ultrasound guidance or in theatre conditions
(3) The absence of any national guidance in respect of Mini Tracheostomy Procedures to minimise the risks associated with them particularly the risks of conducting such procedures outside of an operating theatre and without ultrasound guidance
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for Mini Tracheostomy Procedures
Wider context from the report “(1) The Continuing risk of mortality where Mini Tracheostomy Procedures are not undertaken within theatre conditions or ultrasound guided
(2) That Mini Tracheostomy Procedures are undertaken regularly on a national level without ultrasound guidance or in theatre conditions
(3) The absence of any national guidance in respect of Mini Tracheostomy Procedures to minimise the risks associated with them particularly the risks of conducting such procedures outside of an operating theatre and without ultrasound guidance
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Risk of mortality from Mini Tracheostomy Procedures undertaken without theatre conditions or ultrasound guidance
Wider context from the report “(1) The Continuing risk of mortality where Mini Tracheostomy Procedures are not undertaken within theatre conditions or ultrasound guided
(2) That Mini Tracheostomy Procedures are undertaken regularly on a national level without ultrasound guidance or in theatre conditions
(3) The absence of any national guidance in respect of Mini Tracheostomy Procedures to minimise the risks associated with them particularly the risks of conducting such procedures outside of an operating theatre and without ultrasound guidance
” 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 Ultrasound is mainly limited to planning and landmark identification, while bleeding can occur with or without prior ultrasound.
Verbatim wording from the response “However, FICM and RCOA point out that ultrasound is largely limited to pre-procedure planning and anatomic landmark identification as the size and shape of most available probes makes real-time scanning impractical. They also point out that bleeding can occur with or without prior use of ultrasound.” Source location 2016-0152-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 Routine ultrasound before mini tracheostomy is not mandated because it is not currently feasible for several reasons.
Verbatim wording from the response “FICM and RCOA have reviewed your Regulation 28 report and provided a joint response to the issues you raise (enclosed). They confirm that routine use of ultrasound is not mandated prior to mini tracheostomy as it is not currently feasible to do so for a number of reasons. The Intensive Care Society and FICM are developing ways to standardise ultrasound access training in order to make it more accessible.” Source location 2016-0152-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 An appropriately equipped critical care unit is considered a suitable setting for mini tracheostomy procedures.
Verbatim wording from the response “With regard to carrying out a mini tracheostomy procedure, FICM and RCOA confirm that an appropriately equipped critical care unit is and would be a suitable setting.” Source location 2016-0152-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 reviews, guidance and best-practice materials address tracheostomy safety and support, so additional national guidance is not identified as necessary.
Verbatim wording from the response “Various reviews and professional guidance have been published for England concerning the safe use of Tracheostomy and the care of patients undergoing this treatment:” Source location 2016-0152-Response-by-Department-of-Health
Open published response
7 Apr 2016 Joyce Carney · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 4 Lack of agreed police-hospital protocols for joint risk assessments and liaison View source Failure of police-hospital liaison and communication during risk assessment of police-supervised hospital patients View source Failure of risk assessments for police-supervised hospital patients to protect other patients, visitors, members of the public and staff View source Failure of senior police officers to reassess risk after concerns about an agitated patient threatening to leave hospital 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
Joyce Carney · 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
Joyce Carney, who had diabetes and dementia, was knocked to the floor in a hospital corridor by another patient running away from Police Officers. She sustained a fractured neck of femur, underwent surgery, developed infections and deteriorated before dying on 11 February 2015. The principal concerns were the lack of communication and joint risk assessment between Police and Hospital staff, and the absence of protocols to protect other patients, visitors, the public and staff when patients are supervised by Police Officers.
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 agreed police-hospital protocols for joint risk assessments and liaison
Wider context from the report “iv. There are no agreed protocols, policies or procedures between the Greater Manchester Police and the Royal Albert Edward Infirmary, Wigan in relation to joint risk assessments for patients detained at the Hospital under arrest or in the presence of or supervised by Police Officers. Furthermore there is no protocol, in relation to liaison and consultation between the Greater Manchester Police and the Hospital to formulate risk assessments in relation to patients detained at the Hospital under arrest or in the presence of or supervised by Police Officers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 police-hospital liaison and communication during risk assessment of police-supervised hospital patients
Wider context from the report “i. When the Patient was moved to Lowton Ward in the Hospital the risk assessment conducted by the Hospital in relation to the location of the Patient in the Ward involved the Bed Manager, the Ward Manager and the Nurses treating the Patient. The risk assessment did not involve, nor include, the Police Officers who were observing a patient. The risk assessment conducted by the Hospital focussed on the safety of the Patient and did not extend to the safety of other patients in the Hospital, visitors to the Hospital, members of the public and members of staff employed in the Hospital.
ii. The risk assessment conducted by Police Officers, in relation to the Patient at the Hospital, focussed on the Patient and the fact that the Patient may seek to leave the Hospital but the assessment did not include any discussions or liaison with Hospital staff. The risk assessment did not include the protection of other patients in the Hospital, visitors to the Hospital, members of the public or staff employed in the Hospital.
iii. There was no liaison or communication between the Police Officers observing the Patient and the Hospital treating the Patient in relation to the layout of the Hospital or with regard to the safety of other patients in the Hospital, visitors to the Hospital, members of the public and staff employed in the 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 of risk assessments for police-supervised hospital patients to protect other patients, visitors, members of the public and staff
Wider context from the report “i. When the Patient was moved to Lowton Ward in the Hospital the risk assessment conducted by the Hospital in relation to the location of the Patient in the Ward involved the Bed Manager, the Ward Manager and the Nurses treating the Patient. The risk assessment did not involve, nor include, the Police Officers who were observing a patient. The risk assessment conducted by the Hospital focussed on the safety of the Patient and did not extend to the safety of other patients in the Hospital, visitors to the Hospital, members of the public and members of staff employed in the Hospital.
ii. The risk assessment conducted by Police Officers, in relation to the Patient at the Hospital, focussed on the Patient and the fact that the Patient may seek to leave the Hospital but the assessment did not include any discussions or liaison with Hospital staff. The risk assessment did not include the protection of other patients in the Hospital, visitors to the Hospital, members of the public or staff employed in the Hospital.
iii. There was no liaison or communication between the Police Officers observing the Patient and the Hospital treating the Patient in relation to the layout of the Hospital or with regard to the safety of other patients in the Hospital, visitors to the Hospital, members of the public and staff employed in the 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 of senior police officers to reassess risk after concerns about an agitated patient threatening to leave hospital
Wider context from the report “Furthermore the Officers at the Hospital raised concerns with their Supervising Officer, namely a Sergeant at the Police Station, in relation to the Patient being agitated and threatening to leave the Hospital during the afternoon of the 21st December 2014 but neither the Sargent nor any other senior Officer attended the Hospital to conduct any further risk assessment or to reassess the situation .
” Open source report
Concerns raised 1 Failure to rebut a cost-based presumption in favour of vaginal delivery View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kristian Andrew Jaworski · 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
Kristian Andrew Jaworski was born following a prolonged instrumental delivery involving ventouse and forceps, followed by an emergency caesarean section. He was born with poor Apgar scores and died five days later; the report identified a concern that vaginal delivery was presumed partly on the basis of cost.
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 rebut a cost-based presumption in favour of vaginal delivery
Wider context from the report “That there was a presumption in favour of vaginal delivery based partly of cost that needed to be rebutted .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The hospital trust must consider why caesarean delivery was not attempted earlier and whether cost influenced that decision.
Verbatim wording from the response “I am unable to comment on why a caesarean delivery was not attempted at an earlier opportunity in this case or whether that decision was based in any way on cost – this is clearly something that the North Middlesex University Hospital NHS Trust needs to consider. I will ensure that a copy of your letter and this reply are sent to the Trust to give them the opportunity to respond to your concern.” Source location 2016-0125-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 The Department cannot comment on why caesarean delivery was not attempted earlier or whether cost influenced that decision.
Verbatim wording from the response “I am unable to comment on why a caesarean delivery was not attempted at an earlier opportunity in this case or whether that decision was based in any way on cost – this is clearly something that the North Middlesex University Hospital NHS Trust needs to consider. I will ensure that a copy of your letter and this reply are sent to the Trust to give them the opportunity to respond to your concern.” Source location 2016-0125-Response-by-Department-of-Health
Open published response
17 Mar 2016 Jacqueline Emma Brown Scott · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 7 Failure of the BIPAP display to keep the battery-power indicator visible during multiple alarms View source Lack of an isolated power supply for ward beds routinely using life-saving equipment View source Failure to train BIPAP staff to recognise battery-power indicators and battery-depletion alarms View source Failure to repair emergency call bells after notification of a fault View source Lack of a system or check to alert ward staff to local mains-power failure View source Failure of the BIPAP alarm system to provide a distinct urgent warning for battery depletion View source Conflict between electrical-safety guidance for clinical risk areas View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jacqueline Emma Brown Scott · 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
Jacqueline Emma Brown Scott was admitted to hospital on 31 March 2015 with worsening shortness of breath and reduced mobility and was treated with a BIPAP machine. The machine was running on battery because of a failed power socket, but this was not recognised before the battery ran out; she died shortly afterwards. Concerns included the machine’s battery warnings and alarms, staff training, ward power provision and the absence of systems to identify power failures.
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 BIPAP display to keep the battery-power indicator visible during multiple alarms
Wider context from the report “(i)The BIPAP Trilogy 202 machine had a subtle visual display symbol which denoted when the machine was running on battery power. That symbol is not visible if there are many alert alarms as the alarm messages fill up the screen as they come in pushing the earlier alerts (including low battery) off the screen. In Mrs Scott’s case there had been 17 alert alarms in the space of 50 minutes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 isolated power supply for ward beds routinely using life-saving equipment
Wider context from the report “(iv) Richmond ward ADU beds was designated as a category 4 area which in this case meant there was no isolated power supply (IPS) provided to the ward notwithstanding life-saving equipment was routinely used .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 train BIPAP staff to recognise battery-power indicators and battery-depletion alarms
Wider context from the report “(iii) Staff who were experienced and trained on the BIPAP machine did not appear to be trained to be alert to the situation or to the significance of a battery symbol showing on the machine when the machine was plugged in to the mains or to any particular alarm which denoted battery depletion rather than mask slippage .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 repair emergency call bells after notification of a fault
Wider context from the report “(vii) The crash bell for bed bay 5 did not work when the emergency arose . However estates management had been notified some days earlier of the broken patient call in the same bay . This was of concern as both emergency bells were on the same circuit and not fixed until 2 April 2014 when by chance the failure of electricity was 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 Lack of a system or check to alert ward staff to local mains-power failure
Wider context from the report “(vi)There was no system or check that would alert ward staff to the failure of mains power in any particular area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 BIPAP alarm system to provide a distinct urgent warning for battery depletion
Wider context from the report “(ii)The BIPAP Trilogy 202 machine has the same alarm sound for battery depletion as for circuit disconnect (where for example the face mask slipped) which was the more usual and expected reason for an alarm and these two factors separately and together did not have any feature of urgent warning to alert staff to battery depletion .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Conflict between electrical-safety guidance for clinical risk areas
Wider context from the report “(v) Hospital Technical Memoranda (HTM) 06-01 Part A provides advice and guidance and a benchmark standard for electrical installation, maintenance and safety etc in healthcare premises. It is a matter of concern that there is a conflict of advice between clause 4.22 and Clause 6.62 . Clause 4.22 states: “Clinical treatment and patient safety may be compromised ( but not endangered) by any interruption of electrical supply “ whereas Clause 6.62 states: “In clinical risk Category 4 and 5 areas the patient environment should have at least two IPS circuits at the bedhead”
” 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 Consider the adequacy of HTM guidance on alerts relating to power-supply interruptions.
Verbatim wording from the response “The HTM also provides guidance on the provision of audible and visual alarms in relation to interruptions to power supply failures and the need to provide indication at the nurse’s station for the relevant medical area.” Source location 2016-0112-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 Review relevant HTM sections within the wider technical guidance programme to determine whether greater clarity is needed.
Verbatim wording from the response “For the reasons set out above, the Department does not consider that there is a conflict of advice in the HTM. However, the concerns you raise are noted and the relevant sections of the HTM will be considered and reviewed, as part of the wider technical guidance programme, to determine if there is a need for greater clarity. Similarly, the issue of alerts will be considered, although the HTM is considered to provide adequate guidance on this issue.” Source location 2016-0112-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 Manufacturers cannot be compelled to improve compliant devices without changes to UK and EU regulatory requirements.
Verbatim wording from the response “My officials contacted colleagues at NHS England who have advised that the design of some non-invasive ventilation (NIV) systems and other critical devices could be improved by having safety features which warn staff of delivery problems, such as disconnection and power failure. NHS England has a close working relationship with the Medicines and Healthcare Regulatory Agency (MHRA) and is able to share such concerns with them. Their collective power to improve the design of medical devices is often limited however, as manufacturers are not required to make changes to a product if it” Source location 2016-0112-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 HTM guidance is considered adequate regarding alerts for interruptions to power supply.
Verbatim wording from the response “The HTM also provides guidance on the provision of audible and visual alarms in relation to interruptions to power supply failures and the need to provide indication at the nurse’s station for the relevant medical area.” Source location 2016-0112-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 The Department does not consider HTM 06-01 clauses 4.22 and 6.62 to conflict when read together.
Verbatim wording from the response “With regard to issues around the provision of power to the ward, you quote from our Department’s Hospital Technical Memoranda (HTM) 06-01 and consider that there is a conflict of advice in Part A between clauses 4.22 and 6.62.” Source location 2016-0112-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 Many concerns require action by Philips Healthcare and the NHS Foundation Trust rather than the Department.
Verbatim wording from the response “Many of these issues need to be addressed by Phillips Healthcare and the NHS Foundation Trust. However, I do acknowledge your concerns about the design of the BiPAP machine and the safe provision of power supply which I will address.” Source location 2016-0112-Response-by-Department-of-Health
Open published response
16 Mar 2016 Helen England · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1 Lack of protocol or guidance for Mental Health Nurses on referring acute-hospital discharge decisions to a doctor after self-harm 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 England · 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 England, who had bipolar affective disorder and was subject to a Community Treatment Order, was found hanging in her home on 26 December 2013 after recent self-harm, hospital discharge and concerns about her safety. The principal concern was that there was no protocol or guidance for mental health nurses on whether to refer discharge decisions to a doctor, particularly when a patient subject to a Community Treatment Order had attended or been admitted to hospital following self-harm.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of protocol or guidance for Mental Health Nurses on referring acute-hospital discharge decisions to a doctor after self-harm
Wider context from the report “There was no protocol nor any guidance in place for Mental Health Nurses at the 5 Boroughs NHS Partnership Foundation Trust to follow when considering whether or not to refer to a Doctor a decision to discharge a patient, following an attendance at, or admission to, an acute Hospital consequent upon an episode of self-harm , particularly when the patient is subject to a Community Treatment Order imposed under the terms of the Mental Health Act .
” Open source report
16 Mar 2016 Steven James May · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 10 Inadequate First Aid training for prison staff View source Selective emergency First Aid training among prison staff View source Lack of mental health experience and/or training among reception nursing staff View source Involvement of prison staff lacking relevant training or appropriate rank in the ACCT process View source Hesitancy to enter a cell during an emergency because of an instruction not to enter cells alone View source Failure to ensure medical professional attendance at First Care Reviews View source Failure of reception nursing staff to consult historical medical notes during reception interviews View source Limited accessibility of health and/or mental health care during weekends and Bank Holidays View source Reliance on verbal handovers rather than written records for prisoner information View source Failure to prepare sufficiently full ACCT assessment notes View source See 7 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
Steven James May · 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
Steven James May died by hanging at HMP Ranby on 25 May 2015 at 01:45, after previously expressing suicidal intent and being placed on the ACCT programme. The report identified concerns about failures in reception health screening, ACCT documentation and reviews, information handovers, staff training and involvement, emergency first aid, cell-entry procedures, and access to health and mental health care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate First Aid training for prison staff
Wider context from the report “(9) The inadequacy of First Aid training provided to prison staff in any event (namely, the administration of CPR by prison staff whilst the deceased was lying on a bed );
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Selective emergency First Aid training among prison staff
Wider context from the report “(7) The selective training of prison staff in emergency First Aid (namely the first member of prison staff on the scene of the death was not trained in the administration of CPR and was ignorant of the location of and method of use of defibrillators );
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of mental health experience and/or training among reception nursing staff
Wider context from the report “(2) The lack of experience and/or training of reception nursing staff in the field of mental health ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Involvement of prison staff lacking relevant training or appropriate rank in the ACCT process
Wider context from the report “(5) The involvement in the ACCT process of prison staff possessing neither relevant training nor the appropriate rank ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Hesitancy to enter a cell during an emergency because of an instruction not to enter cells alone
Wider context from the report “(8) The hesitancy of the first member of prison staff on the scene to enter the deceased’s cell in apparent adherence to an instruction not to enter cells alone ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure medical professional attendance at First Care Reviews
Wider context from the report “(6) The failure of prison staff to ensure the attendance of a medical professional at the First Care Review ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 reception nursing staff to consult historical medical notes during reception interviews
Wider context from the report “(1) The failure of reception nursing staff , by reason of lack of training and/or instruction or lack of staff and/or time , to consult the deceased’s historical medical notes prior to or during the reception interview ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Limited accessibility of health and/or mental health care during weekends and Bank Holidays
Wider context from the report “(10) The accessibility of health and/or mental health care to inmates at weekends and during Bank Holidays .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Reliance on verbal handovers rather than written records for prisoner information
Wider context from the report “(4) Reliance by prison staff on verbal and/or oral handovers of information, rather than written records , regarding the deceased ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 prepare sufficiently full ACCT assessment notes
Wider context from the report “(3) The failure of prison staff when preparing the ACCT document to prepare as full a note as possible . For example, to follow the subject areas suggested in the narrative accompanying sections 1-8 of the Assessment Interview ;
” Open source report
Concerns raised 2 Failure to hand over known or suspected difficult airway information to paediatric anaesthetists View source Lack of a nationally agreed neonatal airway assessment classification 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
Amelia Celestine Calvo · 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
Amelia Celestine Calvo was born prematurely with Edwards Syndrome and oesophageal atresia with a tracheo-oesophageal fistula. During surgery, her endotracheal tube became dislodged, after which she developed severe airway problems, pneumothoraces and bleeding, and died despite resuscitation. Concerns included communication failures about the risk of a difficult airway and the absence of a national guideline for using the airway grading classification in neonatal practice.
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 hand over known or suspected difficult airway information to paediatric anaesthetists
Wider context from the report “1. During the course of the inquest, I heard evidence from ████████ Consultant Neonatologist, the independent expert instructed by the court that the grading system used by anaesthetists to assess a patient's throat prior to carrying out a laryngoscopy and assessment generally, namely the view being classified as follows:
o Grade I: Complete glottis visible
o Grade II: Anterior glottis not seen
o Grade III: Epiglottis seen, but not glottis
o Grade IV: Epiglottis not seen
is not a classification that is generally used in neonatal practice.
████████ advised that in fact this classification was ‘rarely’ used in neonatal practice and that there were discussions currently being undertaken as to creating a joint anaesthetic/neonatal guideline.
In Amelia’s case, the issue was as to whether or not there was a ‘difficult/dangerous’ airway was not handed over by the neonatologists to the paediatric anaesthetist prior to the surgery on 28 March 2014 as the neonatologists did not consider 4 attempts at intubation at birth to be indicative of a difficult airway .
████████ additionally stated that in his Trust discussions were taking place in the neonatology department with regard to using this classification system, but there is no national guideline to this effect.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 nationally agreed neonatal airway assessment classification
Wider context from the report “1. During the course of the inquest, I heard evidence from ████████ Consultant Neonatologist, the independent expert instructed by the court that the grading system used by anaesthetists to assess a patient's throat prior to carrying out a laryngoscopy and assessment generally, namely the view being classified as follows:
o Grade I: Complete glottis visible
o Grade II: Anterior glottis not seen
o Grade III: Epiglottis seen, but not glottis
o Grade IV: Epiglottis not seen
is not a classification that is generally used in neonatal practice.
████████ advised that in fact this classification was ‘rarely’ used in neonatal practice and that there were discussions currently being undertaken as to creating a joint anaesthetic/neonatal guideline.
In Amelia’s case, the issue was as to whether or not there was a ‘difficult/dangerous’ airway was not handed over by the neonatologists to the paediatric anaesthetist prior to the surgery on 28 March 2014 as the neonatologists did not consider 4 attempts at intubation at birth to be indicative of a difficult airway.
████████ additionally stated that in his Trust discussions were taking place in the neonatology department with regard to using this classification system, but there is no national guideline to this effect.
” Open source report
8 Mar 2016 Elsie Tindle · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 2 Failure to provide timely SOAD appointments View source Failure to prevent default use of s62 MHA urgent powers 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
Elsie Tindle · 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
Elsie Tindle, who had severe depressive disorder with suspected cognitive impairment and a learning disability, received three ECT sessions in February and March 2015. She developed focal seizures and status epilepticus, later appeared to develop aspiration pneumonia, and died on 4 April 2015; the post-mortem recorded anoxic-ischaemic brain damage due to status epilepticus due to ECT. The principal concerns were delays in appointing SOADs and the risk that the urgent s62 MHA powers could become a default position when SOAD appointments were delayed.
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 timely SOAD appointments
Wider context from the report “(2) For ECT, SOADs attend within 5 days in 82% of cases but I am concerned that in 1:5 cases this does not happen .
(3) Practitioners anticipate delays with the appointment of SOADs and it is common to use the urgent powers under s62 MHA (it is immediately necessary to save the patient’s life or prevent a serious deterioration in their condition).
(4) I am concerned that there is a danger of the use of s62 MHA becoming a default position and that the numbers of SOADs may be insufficient to deal with matters in a more timely way .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent default use of s62 MHA urgent powers
Wider context from the report “(2) For ECT, SOADs attend within 5 days in 82% of cases but I am concerned that in 1:5 cases this does not happen.
(3) Practitioners anticipate delays with the appointment of SOADs and it is common to use the urgent powers under s62 MHA (it is immediately necessary to save the patient’s life or prevent a serious deterioration in their condition).
(4) I am concerned that there is a danger of the use of s62 MHA becoming a default position and that the numbers of SOADs may be insufficient to deal with matters in a more timely way.
” Open source report
Concerns raised 3 Inconsistent use of intrapartum antibiotics View source Inconsistent treatment guidance and practice for prolonged rupture of membranes View source Inconsistent GBS screening practice during pregnancy View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Edward Paddon-Bramley · 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
Edward Paddon-Bramley was born following prolonged rupture of membranes and developed severe infection, including Group B Streptococcus infection. Despite neonatal care, he died aged 9 days. The report identified differing practices and opinions regarding the treatment of prolonged rupture of membranes and whether pregnant women should be screened for Group B Streptococcus and given intrapartum antibiotics.
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 Inconsistent use of intrapartum antibiotics
Wider context from the report “Evidence was provided to the Court by way of National guidelines (NICE 2008, Induction of labour), Trust guidelines (more than one Trust), The Royal College (Green-top guideline no 36) and by Consultants.
Trust guidelines as to the treatment of prolonged rupture of membranes (PROM) differed from those provided by NICE and the use of anti-biotics, after varying times of rupture, irrespective of the clinical picture.
Consultants views as to the best practice for treating PROM and whether women should be screened for GBS during pregnancy differed from those provided by NICE.
In conclusion, evidence was given at the inquest that there is a difference of opinion and practice in the treatment of mothers (and their babies) who suffer from ROM of a prolonged period. Both clinicians and Trusts appear to be at odds with NICE.
There also appears to be arguable opinion that GBS screening in pregnant women together with the use of intra-partum anti-biotics ought to re-viewed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 treatment guidance and practice for prolonged rupture of membranes
Wider context from the report “Evidence was provided to the Court by way of National guidelines (NICE 2008, Induction of labour), Trust guidelines (more than one Trust), The Royal College (Green-top guideline no 36) and by Consultants.
Trust guidelines as to the treatment of prolonged rupture of membranes (PROM) differed from those provided by NICE and the use of anti-biotics, after varying times of rupture, irrespective of the clinical picture.
Consultants views as to the best practice for treating PROM and whether women should be screened for GBS during pregnancy differed from those provided by NICE.
In conclusion, evidence was given at the inquest that there is a difference of opinion and practice in the treatment of mothers (and their babies) who suffer from ROM of a prolonged period. Both clinicians and Trusts appear to be at odds with NICE.
There also appears to be arguable opinion that GBS screening in pregnant women together with the use of intra-partum anti-biotics ought to re-viewed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 GBS screening practice during pregnancy
Wider context from the report “Evidence was provided to the Court by way of National guidelines (NICE 2008, Induction of labour), Trust guidelines (more than one Trust), The Royal College (Green-top guideline no 36) and by Consultants.
Trust guidelines as to the treatment of prolonged rupture of membranes (PROM) differed from those provided by NICE and the use of anti-biotics, after varying times of rupture, irrespective of the clinical picture.
Consultants views as to the best practice for treating PROM and whether women should be screened for GBS during pregnancy differed from those provided by NICE.
In conclusion, evidence was given at the inquest that there is a difference of opinion and practice in the treatment of mothers (and their babies) who suffer from ROM of a prolonged period. Both clinicians and Trusts appear to be at odds with NICE.
There also appears to be arguable opinion that GBS screening in pregnant women together with the use of intra-partum anti-biotics ought to re-viewed.
” 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 Current evidence does not support universal antenatal screening for group B streptococcal carriage.
Verbatim wording from the response “The UK National Screening Committee (UK NSC) advises Ministers and the NHS in all four countries about all aspects of screening policy and supports implementation. Using research evidence, pilot programmes and economic evaluation, it assesses the evidence for programmes against a set of internationally recognised criteria. In the case of screening for GBS carriage in pregnancy, the current evidence does not support universal screening.” Source location 2016-0099-Response-by-Department-of-Health
Open published response
Concerns raised 1 Failure of vaccination policy to include vaccination of males against the virus 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
Curt Falk · 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
Curt Falk was diagnosed with squamous cell carcinoma of the tongue and a blood disorder categorised as high-risk myelodysplasia or acute myeloid leukaemia. He underwent curative radiotherapy for the cancer, but this meant the blood disorder was not treatable before his death from acute myeloid leukaemia on 6 July 2015. The report raised concern that vaccination policy did not include vaccinating males against the virus associated with the cancer, creating a risk of future deaths in men from its consequences.
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 vaccination policy to include vaccination of males against the virus
Wider context from the report “(1) The SCC from which Mr Falk suffered resulted from a viral infection, which is now potentially preventable through vaccination. This issue did not form part of the evidence heard at the inquest because it was not directly relevant to Mr Falk’s death. However, I am concerned that current vaccination policy does not include the vaccination of males against this virus . As such, there is a risk that future deaths could occur in men from the consequences of this infection.
” Open source report
25 Feb 2016 Amy Rose COOPER · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1 Lack of compatible digital record-keeping and medical note systems enabling information sharing between maternity services 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
Amy Rose COOPER · 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
Amy was born at 40 weeks’ gestation by caesarean section on 8 July 2015 and required immediate resuscitation before being confirmed dead later that evening. Intrauterine growth restriction was not evident to the community midwives or hospital maternity unit until post-mortem investigations; the report also raised concerns about incompatible record-keeping systems and the sharing of maternity information between services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of compatible digital record-keeping and medical note systems enabling information sharing between maternity services
Wider context from the report “It was clear at the inquest that maternity services which had been commissioned in this region had not been required to have a specification for record keeping, notes and scans which could be digitally available to other maternity services operating in the same area . Such that Arrowe Park Hospital needed to have the paper notes from One to One North West Ltd. to ensure continuity of care.
This does not appear to be the most efficient system for continuity of patient care and could have been remedied by the commissioners of the services requiring compatible record keeping and medical note systems to ensure the easy sharing of information .
This would also enable community based midwives to refer a patient to a consultant without the patient necessarily having to attend the maternity unit in the first place.
Further access to notes would make the admission to the maternity unit safer and seamless, delivering what should be a better patient experience and outcome.
” Open source report
15 Feb 2016 Adam James Withers · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Failure to identify retrospective patient-record entries View source Lack of clear guidance on preserving original records after a patient’s death View source Insufficient recording of psychiatric patient observations and interactions View source Lack of prescribed safe nursing staffing levels for acute psychiatric wards 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
Adam James Withers · 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
Adam James Withers, who was suffering from an acute psychotic illness and detained in hospital, climbed a 130-foot chimney and fell from it, suffering fatal injuries. The report identified concerns about failures to manage his known risk of absconding, reassess his risk after he spoke about climbing the chimney ladder, prevent access to the ladder, communicate environmental risks, and ensure adequate supervision and reliable record-keeping.
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 identify retrospective patient-record entries
Wider context from the report “It was clear from the evidence that any note made in a patient’s record should be made contemporaneously or, if made later, should be timed, dated and labelled as retrospective . This is necessary to ensure that all notes are accurate and reliable.
The evidence at the inquest revealed that at least one member of nursing staff made entries on Adam Withers’ manuscript observation record after he had died, without marking the entries as retrospective . When giving evidence, the member of staff in question did not appear to understand that he ought not to have done so.
If permitted to continue, this practice could result in current and future patients’ notes containing inaccurate and unreliable, and potentially misleading, information and this could have an adverse impact on their assessment, treatment and care and upon the protection of their lives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance on preserving original records after a patient’s death
Wider context from the report “At the inquest an issue arose as to when the manuscript observation record for Adam Withers for the 9th May 2014 was completed and I asked to see the original document. I was provided with a witness statement from the Trust’s Medical Records Manager indicating that, after Adam Withers’ death, the original record had been scanned in to his electronic records and then destroyed. The Trust considers that this is permitted by the NHS Code of Practice on Record Management. It is not clear to me whether that is a correct analysis of the Code or not. No clear guidance appears to exist .
Whilst I understand that paper records may now routinely be scanned in to a patient’s electronic record and then destroyed, my concern relates to that taking place after a patient has died and it is apparent that the death must be reported to the police and/or coroner. The destruction of any original document which is still in existence at the time of death could undermine the efficacy of the police investigation and/or the coroner’s investigation. In turn, this could adversely affect the coroner’s ability to establish the facts of how the deceased person came by his death and to report concerns for the prevention of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient recording of psychiatric patient observations and interactions
Wider context from the report “It was apparent from the evidence that periodic observations of psychiatric patients are conducted not only to check that each is present, but also in order to observe and assess their current state of mind and presentation, by means of a meaningful interaction, if possible. The importance of nursing staff (Registered Nurses and Health Care Assistants) making a sufficient written record of these observations was acknowledged. Regular notes of a patient’s condition are important for the purposes of diagnosis and they provide the information which is needed for a reliable assessment of the patient’s progress and current level of risk of harm or death. It was accepted in evidence that this is especially so in relation to any patient whose condition fluctuates.
It was clear from the evidence that the nursing staff involved in Adam Withers’ care failed to record sufficiently his presentation and their interactions with him . For example, on the day of his death Adam Withers was subject to four observations per hour but no entries were made on his RIO notes or elsewhere about his state of mind or presentation at these observation points and no record was made about the conversation a nurse conducted with him that afternoon .
Some of the nursing staff who gave evidence appeared to have little understanding of the need to make such written records and/or their importance .
If permitted to continue, the insufficient recording of observations and events could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of prescribed safe nursing staffing levels for acute psychiatric wards
Wider context from the report “At the inquest the number of nursing staff (Registered Nurses and Health Care Assistants) on duty on Elgar Ward was considered. It was apparent from the evidence that the nursing staff levels could result in patients on the ward being insufficiently supervised at meal times and staff stated in evidence that they did not always have time to read patients’ notes as they should.
Further, Elgar Ward is an acute psychiatric ward with both detained and voluntary patients. It is foreseeable that reactive and unplanned interventions will be required at times and that the level of observation needed by each patient will fluctuate. The staffing levels on Elgar Ward were deemed sufficient for only a fixed number of patients to be subject to increased observation levels, and only one patient to be under constant observation, at any one time. I was informed that if more patients required increased or constant observation, additional staff would be needed but may not be readily available.
I have been told by the Trust that no nationally prescribed safe staffing levels are in place for an acute psychiatric ward (whether based on patient to staff ratios or otherwise) and that the Trust considers its staffing levels to be in accordance with such guidelines as do exist. The Mental Health Taskforce’s recently published report entitled “The Five Year Forward View For Mental Health” does not appear to address this issue.
It does seem that the absence of prescribed safe nursing staff levels for acute psychiatric wards could leave such wards unable to provide, throughout each shift, the level of patient supervision, observation and intervention needed . This could adversely affect the staff’s ability to protect their patients’ lives.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add clear guidance on retaining original paper records after a potentially reportable death to the revised NHS Records Management Code before publication.
Verbatim wording from the response “The NHS Records Management Code of Practice is currently under review and a revised Code is due to be published when the review is complete. Clear guidance on the point you raise will be added to the revised Code before publication.” Source location 2016-0059-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 Minimum staffing numbers or ratios would not guarantee safety because evidence is lacking and they would ignore local circumstances, skill mix and case mix.
Verbatim wording from the response “We do not agree that a minimum staffing level for services would be a “guarantee for safety”: the evidence base is lacking and minimum staffing numbers and ratios would not take account of local circumstances, skill mix or case mix. Following publication of the revised guidance by NQB, further outputs will be developed by the national programme for individual settings including mental health and learning disability settings.” Source location 2016-0059-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 determining staffing numbers and skill mix rests with individual Trust boards, taking account of local circumstances.
Verbatim wording from the response “Responsibility for staffing rests (as it has always done) with Trust boards. Trusts’ staffing arrangements should enable the right numbers and skill mix of staff at the right time to deliver quality care and patient safety while doing so efficiently, taking into account local factors such as acuity, case mix and how to respond to fluctuations in workload.” Source location 2016-0059-Response-by-Department-of-Health
Open published response
Concerns raised 2 Need for improvement in central venous line insertion processes View source Need for improvement in central venous line removal processes 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
Peter Charles Tye · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Charles Tye was admitted to Derriford Hospital with pneumonia and respiratory failure, and a central venous line was mistakenly inserted into his carotid artery. He later deteriorated with gram-negative sepsis and died; concerns focused on improving the insertion and removal of central venous lines to reduce deaths from misplaced lines.
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 Need for improvement in central venous line insertion processes
Wider context from the report “At an Inquest touching the death of Peter Charles Tye, I received evidence from ████████ that improvements at Derriford Hospital had been made following the events during which a central venous line was misplaced into an artery. A Root Cause Analysis has indicated various improvements which can be made. These improvements concern both the insertion and the removal of central venous lines. Adoption of those processes is likely to reduce the numbers of deaths from misplaced lines.
Details have been shared with the Faculty of Intensive Care Medicine. In my view deaths might be reduced by the promulgation of this good practice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Need for improvement in central venous line removal processes
Wider context from the report “At an Inquest touching the death of Peter Charles Tye, I received evidence from ████████ that improvements at Derriford Hospital had been made following the events during which a central venous line was misplaced into an artery. A Root Cause Analysis has indicated various improvements which can be made. These improvements concern both the insertion and the removal of central venous lines. Adoption of those processes is likely to reduce the numbers of deaths from misplaced lines.
Details have been shared with the Faculty of Intensive Care Medicine. In my view deaths might be reduced by the promulgation of this good practice.
” Open source report
26 Jan 2016 Rio Andrew · Prevention of Future Deaths report South London
View report summary
Concerns raised 5 Lack of regulation of individuals calling themselves ambulance technicians View source Poor medical knowledge among private medical staff View source Failure to ensure the suitability of mentors for trainee medical staff View source Lack of regulation of medical assistance at events View source Lack of protection for the ambulance technician title 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
Rio Andrew · 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
Rio Andrew became unwell after taking MDMA at an illegal rave and was taken to the event medical providers. The inquest concluded that he died from multiple organ failure due to acute MDMA intoxication. Concerns included the lack of regulation of medical assistance at temporary events, poor medical knowledge among private medical staff, the unregulated use of the title “ambulance technician”, and inadequate oversight of training mentors.
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 regulation of individuals calling themselves ambulance technicians
Wider context from the report “(2) This lack of regulation extends to individuals calling themselves ambulance technicians. They are not regulated and the title is not protected.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 medical knowledge among private medical staff
Wider context from the report “(1) The regulation of the private company by the CQC provided false security as to what was in fact being regulated. The only activity that was regulated was transport from the rave in an ambulance on a public road, which activity was not in fact needed because Rio was handed over to the London Ambulance Service outside the venue. The level of medical knowledge displayed by the private medical staff was poor .
The exemption for temporary arrangements means that the provision of medical assistance at events is entirely unregulated. This includes not only illegal raves, but legal events such as sporting events, fetes and festivals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 the suitability of mentors for trainee medical staff
Wider context from the report “(3) Individuals undergoing training at Lifeskills UK Ltd (and possibly other private training providers) are left to find their own mentor(s) without checks being made by the company as to their suitability or any register or panel from which the choice can be 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 Lack of regulation of medical assistance at events
Wider context from the report “(1) The regulation of the private company by the CQC provided false security as to what was in fact being regulated. The only activity that was regulated was transport from the rave in an ambulance on a public road , which activity was not in fact needed because Rio was handed over to the London Ambulance Service outside the venue. The level of medical knowledge displayed by the private medical staff was poor.
The exemption for temporary arrangements means that the provision of medical assistance at events is entirely unregulated . This includes not only illegal raves, but legal events such as sporting events, fetes and festivals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of protection for the ambulance technician title
Wider context from the report “(2) This lack of regulation extends to individuals calling themselves ambulance technicians. They are not regulated and the title is not protected .
” 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 Consult on whether established year-round event medical providers should be brought within CQC regulation.
Verbatim wording from the response “The Department has become aware of some permanent established companies that provide cover at temporary events. These providers deliver services on a year round basis, to one off events and other social and cultural events. The range of services provided appears to go some way beyond basic first aid and in some cases involves the delivery of services by a multi-disciplinary team. The Department is intending to consult later this year as to whether providers of this sort should be brought into the scope of regulation by CQC. The Department is proposing that permanent nature of these providers, as opposed to the temporary nature of the events they provide services at, does offer sufficient continuity of service that system regulation by CQC could help mitigate the risks of the public receiving unsafe care at events.” Source location Rio-Andrew-2016-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 Temporary-event providers remain outside CQC regulation because regulation is ineffective for short events and would impose disproportionate burdens.
Verbatim wording from the response “The CQC does not regulate the “treatment of disease, disorder or injury” where it is delivered under temporary arrangements for the purposes of sporting or cultural events. The rationale for this is because the short term nature of such events means system regulation does not offer an effective mitigation of the risks in the care provided over the course of the event. In most cases, the event would be over before the CQC would have chance to inspect it or provided any sort of assurance about the quality and safety of services provided at the event.” Source location Rio-Andrew-2016-Response-by-Department-of-Health
Open published response
21 Jan 2016 Elvis Terrence Gene Nelson · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Hazard of sedation and respiratory depression when users are unaware that acetylfentanyl is an opioid drug View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Elvis Terrence Gene Nelson · 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
Elvis Terrence Gene Nelson was found unconscious in a hotel room on 27 August 2015 and died later that day despite resuscitation. The cause of death was acetylfentanyl toxicity, with concern that users may be unaware they have purchased or used an opioid drug and may therefore be exposed to sedation and respiratory depression.
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 Hazard of sedation and respiratory depression when users are unaware that acetylfentanyl is an opioid drug
Wider context from the report “During the course of the inquest, I heard evidence from ████████
████████ as to the medical cause of Mr Nelson’s death. She had provided a post mortem report and histopathology report, which incorporated toxicology findings. The evidence I heard confirmed that acetylfentanyl is a ‘designer drug’ and is described as a ‘legal high’. It is an opioid analgesic and I heard evidence that it reported as being 5-15 times more potent than heroin and 80 times more potent than morphine. I understand that it has never been licensed for medical use and has only been sold illegally, but as a ‘legal high’.
It appears to me that although the number of fatalities arising as a result of acetylfentanyl toxicity are low, the toxic effects of this drug being sedation and respiratory depression will be a particular problem if the user is unaware that they have purchased/used an opioid drug .
” Open source report
29 Oct 2015 Hilda Haughton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Fire doors taking increased time to close View source Failure to raise cot sides as required View source Lack of candour by hospital staff 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
Hilda Haughton · 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
Hilda Haughton was admitted to hospital with pneumonia and an acute exacerbation of COPD, and was injured when a fire door was electronically released during a power failure and struck her. The concerns included a subsequent fall from her bed when cot sides had not been raised, alleged lack of candour by hospital staff, and whether the response to the speed and power of electronically released fire doors was adequate.
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 Fire doors taking increased time to close
Wider context from the report “2. The fire-doors are held open by electro-magnets. These are designed to be released remotely to contain any fire which may break out in the hospital. I was told that this type of door fastener is common to very many hospital wards around the U.K. The length of time it takes for the doors to close affects the speed and power with which they move. This time has been increased at Tameside hospital from 3 seconds to 6 seconds. Is this an adequate response and should this issue be raised with all hospitals having these door fasteners? (Secretary of State)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 raise cot sides as required
Wider context from the report “1. Mrs Haughton having sustained the head injury on the 28th April, some 7 days later she was able to fall out of her bed because the cot sides had not been raised as they should have been , and there was a lack of candour by the hospital staff, and this, inter alia, deprived the family of the possibility of seeking a second opinion as to her injuries. (Tameside)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 candour by hospital staff
Wider context from the report “1. Mrs Haughton having sustained the head injury on the 28th April, some 7 days later she was able to fall out of her bed because the cot sides had not been raised as they should have been, and there was a lack of candour by the hospital staff , and this, inter alia, deprived the family of the possibility of seeking a second opinion as to her injuries. (Tameside)
” 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 Issue and publish an Estates and Facilities Safety Alert to NHS organisations covering self-closing fire doors and required risk-reduction actions.
Verbatim wording from the response “Having considered the circumstances of this particular tragic incident and made reference to the British Standard, the Department has issued an Estates and Facilities Safety Alert to the NHS in England.” Source location 2015-0460-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 Controlling fire-door closing times in NHS premises is outside the Department’s power.
Verbatim wording from the response “It is not therefore in the Department’s power to control how long it should take for fire doors to close in NHS premises. Such matters are for local management to decide in light of legislation, advice from relevant professional bodies and in line with recognised safety standards.” Source location 2015-0460-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 Local NHS management must decide fire-door closing times in light of legislation, professional advice and recognised safety standards.
Verbatim wording from the response “It is not therefore in the Department’s power to control how long it should take for fire doors to close in NHS premises. Such matters are for local management to decide in light of legislation, advice from relevant professional bodies and in line with recognised safety standards.” Source location 2015-0460-Response-by-Department-of-Health
Open published response
22 Oct 2015 Harry George Mellor · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Lack of a reliable system to identify children de-registered from a General Practice View source Lack of a legal requirement to register or re-register children with a General Practitioner View source Failure to ensure a new General Practitioner is identified and notified before a child is de-registered View source Failure to directly inform paediatric and physiotherapy services of a child's de-registration 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.
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AI-generated summary
Harry George Mellor · 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
Harry George Mellor, a child with chronic health needs, collapsed unexpectedly on 28 October 2014 and died shortly after arriving at the emergency department. The inquest recorded that he had died from pyelonephritis. Concerns included the lack of a reliable system to identify when a child was de-registered from a GP, potential safeguarding risks when no new GP had been identified, and the paediatric and physiotherapy teams not being informed of the de-registration.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a reliable system to identify children de-registered from a General Practice
Wider context from the report “2. There is no reliable system in place to identify when a child has been de-registered from a General Practice
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a legal requirement to register or re-register children with a General Practitioner
Wider context from the report “1. There is no legal requirement to register or re-register a child with a General Practitioner
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 a new General Practitioner is identified and notified before a child is de-registered
Wider context from the report “3. There are potential safeguarding concerns if a General Practitioner can de-register a child , particularly a child with chronic health needs, before a new General Practitioner has been identified and notified of the proposed de-registration
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 directly inform paediatric and physiotherapy services of a child's de-registration
Wider context from the report “4. The paediatric team and physiotherapy services were not directly informed that Harry was going to be de-registered or had been de-registered
” Open source report
13 Oct 2015 Nathaniel Luke Phillips · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure of GP escalation or reassessment when regular prescriptions are not collected View source Lack of medical exemption coverage for brittle asthma medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nathaniel Luke Phillips · 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
Nathaniel Luke Phillips died at Tameside General Hospital after an acute asthma attack; the inquest recorded hypoxic brain injury due to the attack. Concerns included the cost of regular asthma prescriptions, his apparent loss to adult asthma services, and delays in ambulance availability during his final emergency.
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 GP escalation or reassessment when regular prescriptions are not collected
Wider context from the report “One of the concerns raised by the family and the GP was that a diagnosis of brittle asthma is not one of the illnesses covered by the medical exemption certificate, despite the fact that it is a life-threatening condition requiring medication. It was confirmed that illnesses such as diabetes and epilepsy which require continuous medication are covered.
As indicated earlier due to the cost of his constant medication Nathaniel did not always collect regular prescriptions and relied on family members asthma medication. This meant his GP did not escalate his case or reassess his requirements and asthma control .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of medical exemption coverage for brittle asthma medication
Wider context from the report “One of the concerns raised by the family and the GP was that a diagnosis of brittle asthma is not one of the illnesses covered by the medical exemption certificate , despite the fact that it is a life-threatening condition requiring medication . It was confirmed that illnesses such as diabetes and epilepsy which require continuous medication are covered.
As indicated earlier due to the cost of his constant medication Nathaniel did not always collect regular prescriptions and relied on family members asthma medication. This meant his GP did not escalate his case or reassess his requirements and asthma control.
” 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 Extending medical prescription exemptions to all potentially life-threatening long-term conditions is constrained by significant NHS costs and budget pressures.
Verbatim wording from the response “The list of medical conditions for which patients are exempt from prescription charges was introduced in 1968, with the only addition to this list since then being cancer (in 2009). Ten conditions are included in this list. I believe, it would be unfair to sufferers from other diseases to consider asthma in isolation. However, extending the list to include all potentially life-threatening long term conditions would present a very significant cost to the NHS, which is already facing unprecedented budget pressures.” Source location 2015-0375-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 Existing age-, benefit-, income-related and prescription prepayment arrangements provide alternative help with prescription charges.
Verbatim wording from the response “There are, however, already a number of other routes to exemption from paying prescription charges, should the individual not qualify for a medical exemption. These include children under 16, people aged 60 or over and those in” Source location 2015-0375-Response-by-Department-of-Health
Open published response
7 Oct 2015 Edward Gascoigne · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Failure to make relevant medical-record information accessible to reviewing clinicians View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Edward Gascoigne · 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
Edward Gascoigne, who had worsening confusion and low mood and a history of depressive episodes, was admitted to hospital but discharged without an inpatient psychiatric review. He was subsequently found deceased at an underground station after being hit by a train. The principal concern was that relevant information was held in disparate medical-record systems and was not available to the reviewing psychiatric team.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to make relevant medical-record information accessible to reviewing clinicians
Wider context from the report “(1) Multiple pieces of relevant information regarding Mr Gascoigne’s current illness were contained in disparate record ‘silos’. It was difficult for clinicians to access this information and, as such, it was not available to the reviewing psychiatric team, in particular.
I am concerned that the previous focus on access to medical records, which was to occur through the NHS Programme for IT, has been lost and that the new focus on patient access to GP records will not address the risks posed by the current state of record sharing within the NHS .
” Open source report
Concerns raised 2 PEWS scores distracting doctors from serious illness despite low scores View source PEWS scores not reflecting current research into child illness View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Parv Patel · 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
Parv Patel, aged four, was taken to hospital with an infection and later developed symptoms of heart failure as part of a septic picture. His heart failure was not recognised until later, and intubation precipitated cardiac arrest and death; concerns were raised that PEWS scores may not reflect current research and may distract doctors from recognising serious illness despite a low score.
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 PEWS scores distracting doctors from serious illness despite low scores
Wider context from the report “That PEWS scores do not reflect current research into child illness.
And that the Pews scores may tend to act to distract the doctors away from the fact that despite a low PEWS score a child might be seriously ill
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation PEWS scores not reflecting current research into child illness
Wider context from the report “That PEWS scores do not reflect current research into child illness.
And that the Pews scores may tend to act to distract the doctors away from the fact that despite a low PEWS score a child might be seriously ill
” 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 A single nationally recommended PEWS score cannot yet be established because children’s differing needs make development complex and research is ongoing.
Verbatim wording from the response “NHS England are continuing to work towards developing a consensus view on a paediatric early warning system. There is at present no nationally recommended PEWS score. The complexities of developing a single score are a challenge. It would have to reflect the differing needs and requirements of all children from infants to teenagers, with a range of greatly different underlying healthcare conditions. Developing such a score is the subject of current research funded by the National Institute for Health Research.” Source location 2015-0457-Response
Open published response
28 Sep 2015 Harry Pryal · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 8 Failure to record advice on medical treatment and care View source Failure of Lakeside Unit clinical notes to identify actions, times and clinicians View source Lack of triage procedures for urgent or unexpected significant x-ray findings View source Failure of Lakeside Unit clinicians to understand x-ray request and urgency requirements View source Failure of 5BP and WWL to maintain a shared understanding and interpretation of the Service Agreement View source Unavailability of electronic access to WWL x-rays for 5BP clinicians View source Unavailability of physiotherapy and occupational therapy for Lakeside Unit patients View source Failure of nominated officers to review the operation and performance of Service Agreements View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Harry Pryal · 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
Harry Pryal died on 8 January 2015 after an accidental fall, with the inquest recording bronchopneumonia and traumatic spinal cord injury as the medical cause of death. An X-ray identifying a suspected cervical spine fracture was not reported promptly, and the report raised concerns about communication and record-keeping, conflicting interpretations of a radiology service agreement, access to imaging, and the provision of physical healthcare 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 Failure to record advice on medical treatment and care
Wider context from the report “i. 5BP contact WWL for advise in relation to medical treatment for patients at the Lakeside Unit on a regular basis as a matter of protocol. The Doctors in psychiatry at the Lakeside Unit, are dependent upon such advice for the treatment and care of patients.
The evidence identified that there is no note of the advice in the records maintained by WWL, neither to identify the Doctor giving advice nor the content of the advice . Furthermore evidence was given that this was a situation arising on a nationwide scale. The absence of any notes prevents a record of the advice for the purpose of continuity of treatment and any subsequent referrals , particularly in a case when the Doctor giving the advice is no longer available and further advice is requested by the referring Doctor for medical treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of Lakeside Unit clinical notes to identify actions, times and clinicians
Wider context from the report “v. The evidence at the Inquest revealed that the notes completed by clinicians at the Lakeside Unit, failed to identify the times of actions by them and in one note failed to identify the identity of the clinician making the note . The notes were inadequate , particularly the notes which accompanied Mr Pryal on his transfer from the Lakeside Unit, to RAEI.
The details to be included in a request for x-ray examination and the fact that an urgent x-ray examination required either a telephone call to the Radiologist or a note of priority on the x-ray form did not appear to be understood by clinicians at the Lakeside Unit, and demonstrated a lack of liaison and understanding between the two Trusts, which would be necessary to allow the terms of the Service Agreement to be operated and performed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 triage procedures for urgent or unexpected significant x-ray findings
Wider context from the report “iii. The evidence given by WWL was that there were no time lines in relation to the reporting of x-ray performed at the Leigh Infirmary, other than national timelines , although it was accepted that the Service Agreement provided that “urgent or unexpected significant clinical findings will be communicated to referring clinicians at the time of the Consultant Radiological reporting”. It was accepted if there was an unexpected significant clinical finding it would be necessary to communicate the finding to the referring clinician without delay.
WWL do not have any triage procedures in relation to x-ray examinations so that any “urgent or unexpected significant clinical finding” would not be reported to the referring clinician for some time after the examination . An early triage of the x-ray examination within a short period of the examination would allow any urgent or unexpected significant clinical finding to be communicated to the referring clinician without delay.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Lakeside Unit clinicians to understand x-ray request and urgency requirements
Wider context from the report “v. The evidence at the Inquest revealed that the notes completed by clinicians at the Lakeside Unit, failed to identify the times of actions by them and in one note failed to identify the identity of the clinician making the note. The notes were inadequate, particularly the notes which accompanied Mr Pryal on his transfer from the Lakeside Unit, to RAEI.
The details to be included in a request for x-ray examination and the fact that an urgent x-ray examination required either a telephone call to the Radiologist or a note of priority on the x-ray form did not appear to be understood by clinicians at the Lakeside Unit, and demonstrated a lack of liaison and understanding between the two Trusts, which would be necessary to allow the terms of the Service Agreement to be operated and performed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 5BP and WWL to maintain a shared understanding and interpretation of the Service Agreement
Wider context from the report “ii. The Service Agreement entered into between 5BP and WWL for the period from the 1st April 2014 to the 31st March 2015 was the subject of different interpretations by each Trust. There was confusion in relation to the prioritisation of imaging and there was a fundamental conflict in relation to the interpretation of clause 2.1 .
The Agreement provided for meetings between nominated officers from each trust at intervals not exceeding every 3 months from the effective date of the Agreement to consider any issues arising from the operation and performance of the Agreement, as provided in paragraph 14.1 on page 10 of the Agreement. The evidence of the Inquest confirmed that no meetings had taken place during the concurrence of the Agreement and there was no proactive involvement of the nominated officers to identify any issues arising from the operation and performance of the Agreement. Furthermore evidence was given that there were similar Service Agreements for the period from 1st April 2013 to the 31st March 2014 and from the 1st April 2015 to the 31st March 2016 with similar provisions for meetings during the concurrence of the Agreements but no meetings between nominated officers had ever taken place.
The evidence identified a lack of liaison and understanding between 5BP and WWL in relation to the Agreement and their relationship , even in circumstances where both trusts are operating on the same site at Leigh Infirmary, Leigh.
During the Inquest WWL confirmed that they had similar Service Agreements in relation to the provision of services to health professionals in other areas of treatment and the provisions of all Agreements were similar and the provisions in all Agreements may not be performed in accordance with the requirements of each Agreement.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 electronic access to WWL x-rays for 5BP clinicians
Wider context from the report “iv. 5BP accepted that the Service Agreement provided for web viewing of the x-rays but accepted that the software operated by 5BP does not allow web viewing of x-rays and 5BP did not have network connections to view the x-rays electronically by access to the WWL network . In any event the Consultant Psychiatrist from the Lakeside Unit indicated that the Doctors in her team based at the Lakeside Unit, may not have the expertise to interpret the x-rays on web view and the Doctors would be dependent upon a formal report, either verbal or written, from the Radiologist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 physiotherapy and occupational therapy for Lakeside Unit patients
Wider context from the report “vi. Evidence was given at the Inquest that there was no physiotherapy or occupational therapy at the Lakeside Unit to deal with the physical health needs of any patients on the Unit . There was no Service Agreement for the provision of physiotherapy and occupational therapy and no understanding as to who would provide such services . The evidence indicated that the Clinical Commissioning Group in Wigan would provide the services and 5BP were not in a position to enter into agreements for the provision of services from elsewhere. Evidence was given by 5BP that the Clinical Commissioning Group in Wigan had not provided services so that the physical health needs of patients in the Lakeside Unit, were not being satisfied in relation to physiotherapy and occupational therapy .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 nominated officers to review the operation and performance of Service Agreements
Wider context from the report “ii. The Service Agreement entered into between 5BP and WWL for the period from the 1st April 2014 to the 31st March 2015 was the subject of different interpretations by each Trust. There was confusion in relation to the prioritisation of imaging and there was a fundamental conflict in relation to the interpretation of clause 2.1.
The Agreement provided for meetings between nominated officers from each trust at intervals not exceeding every 3 months from the effective date of the Agreement to consider any issues arising from the operation and performance of the Agreement, as provided in paragraph 14.1 on page 10 of the Agreement. The evidence of the Inquest confirmed that no meetings had taken place during the concurrence of the Agreement and there was no proactive involvement of the nominated officers to identify any issues arising from the operation and performance of the Agreement . Furthermore evidence was given that there were similar Service Agreements for the period from 1st April 2013 to the 31st March 2014 and from the 1st April 2015 to the 31st March 2016 with similar provisions for meetings during the concurrence of the Agreements but no meetings between nominated officers had ever taken place .
The evidence identified a lack of liaison and understanding between 5BP and WWL in relation to the Agreement and their relationship, even in circumstances where both trusts are operating on the same site at Leigh Infirmary, Leigh.
During the Inquest WWL confirmed that they had similar Service Agreements in relation to the provision of services to health professionals in other areas of treatment and the provisions of all Agreements were similar and the provisions in all Agreements may not be performed in accordance with the requirements of each Agreement.
” 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 Local-level services are responsible for implementing the recording of clinical information in patient notes.
Verbatim wording from the response “Whilst the actual recording of patient notes is something that is agreed and implemented at local level, the general move away from paper to integrated digital care records should improve the comprehensiveness of information held, including essential diagnostic tests and it’s availability to all professionals engaged in the care of individual patients.” Source location 2015-0391-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 Local providers are responsible for reviewing local systems concerning X-ray reporting, electronic viewing and patient-note recording.
Verbatim wording from the response “You outline the circumstances which led to this situation and direct several concerns to the 5 Boroughs Partnership NHS Foundation Trust (5BP) and Wrightington Wigan and Leigh NHS Foundation Trust (WWL) which relate to their joint Service Agreement, the reporting times for X-rays, the electronic systems available to support web viewing of X-rays and the recording of appropriate patient notes. These concerns are about the local systems that are in place and rightly addressed to the local providers, who I am confident will consider and review.” Source location 2015-0391-Response-by-Department-of-Health
Open published response
Concerns raised 5 Delays in determining patients’ mental health state View source Lack of resources for dealing with challenging and vulnerable patients View source Delays in recognising patients for whom usual discharge options are unavailable View source Lack of guidelines or protocols for discharging challenging patients View source Delays in approaching nursing homes able to accommodate patients 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
William John Charles Harnell · 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 John Charles Harnell suffered a fractured left hip while attempting to mobilise from his wheelchair on 22 October 2014, remained in hospital, developed hospital-acquired pneumonia and died on 15 December 2014. Concerns included delays in recognising the difficulties surrounding his discharge, assessing his mental health, approaching suitable nursing homes, and a lack of resources and guidance for managing challenging and vulnerable patients.
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 determining patients’ mental health state
Wider context from the report “(2) There appears to have been delay in determining Mr Harnell’s state of mental health
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of resources for dealing with challenging and vulnerable patients
Wider context from the report “(4) There appears to be a lack of resources available for dealing with challenging (and vulnerable) patients like Mr Harnell.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 recognising patients for whom usual discharge options are unavailable
Wider context from the report “(1) There was delay in recognising that Mr Harnell was a most challenging patient for whom the usual means of discharge would not all be available .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidelines or protocols for discharging challenging patients
Wider context from the report “(5) There appears to be no guideline or protocol to assist staff on how best to deal with the discharge of patients like Mr Harnell .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 approaching nursing homes able to accommodate patients
Wider context from the report “(3) There appears to have been delay in approaching the Nursing Homes that may have been able to accommodate him .
” Open source report
Concerns raised 1 Lack of formal monitoring schemes for inexperienced surgeons carrying out surgical procedures 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
Rosalind Jane Anne Bernadette Baird · 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
Rosalind Baird underwent a left nephrectomy during which a blood vessel supplying her bowel was cut. Her condition deteriorated, and she died in hospital on 5 November 2014; the principal concern was the lack of a formal scheme to monitor inexperienced surgeons carrying out surgical procedures.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of formal monitoring schemes for inexperienced surgeons carrying out surgical procedures
Wider context from the report “At the time of Mrs Baird's nephrectomy there was no formal scheme for the monitoring of inexperienced surgeons carrying out surgical procedures . Since that time, Queen Alexandra Hospital has adopted a formal scheme (see attached). I was told that such schemes are not widespread in England and no such scheme has been formulated at national level . To help prevent deaths in circumstances similar to those of Mrs Baird, consideration should be given to a national monitoring scheme for inexperienced consultant surgeons being compiled using the Queen Alexandra Hospital scheme as an example of good practice.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations