18 Oct 2024 Mr Robin Andrew Ward · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 6 Failure of crisis houses to provide ligature-safe environments View source Excessive distance of out-of-area acute beds from patients’ home addresses View source Insufficient clinical capacity and skills mix in crisis houses View source Insufficient provision of acute mental health beds View source Insufficient availability of out-of-area acute beds for elderly patients View source Delays in psychological assessment View source See 3 more concerns
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AI-generated summary
Mr Robin Andrew Ward · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Robin Andrew Ward, a 73-year-old man, died by drowning in a bath at the Warren Crisis House on 4 July 2021; the conclusion was that his death was suicide. He had required an acute inpatient mental health bed, but no local bed was available for four days and he was placed at the crisis house as an interim measure. Concerns included pressures on acute and out-of-area mental health bed availability, the lower clinical capacity and lack of ligature safety in crisis houses, and long waiting times for psychological assessment.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of crisis houses to provide ligature-safe environments
Wider context from the report “a) The Deputy Director for Mental Health at Northamptonshire Healthcare Foundation Trust said in his evidence “there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds”.
b) The Deputy Director also said that “we try to avoid supporting those waiting for an acute bed within crisis houses and continue to use out of area provisions as required and where appropriate”. However, it emerged in evidence that there are also pressures locally and nationally on the availability of out of area acute beds and that this particularly so in relation to provision for the elderly. Even if out of area beds are found, they can be a great distance away from the patient’s home address which can present difficulties including in relation to continuity of treatment. In Mr Ward’s case he was having rTMS treatment during each week day and that treatment is not available in all areas of the Country. This increases the likelihood that a crisis house may be utilised. However a crisis house does not offer the same level of clinical capacity and skills mix as a hospital environment and it is also not a ligature safe environment .
c) Another particular problem identified was the long waiting times for psychological assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Excessive distance of out-of-area acute beds from patients’ home addresses
Wider context from the report “a) The Deputy Director for Mental Health at Northamptonshire Healthcare Foundation Trust said in his evidence “there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds”.
b) The Deputy Director also said that “we try to avoid supporting those waiting for an acute bed within crisis houses and continue to use out of area provisions as required and where appropriate”. However, it emerged in evidence that there are also pressures locally and nationally on the availability of out of area acute beds and that this particularly so in relation to provision for the elderly. Even if out of area beds are found, they can be a great distance away from the patient’s home address which can present difficulties including in relation to continuity of treatment . In Mr Ward’s case he was having rTMS treatment during each week day and that treatment is not available in all areas of the Country. This increases the likelihood that a crisis house may be utilised. However a crisis house does not offer the same level of clinical capacity and skills mix as a hospital environment and it is also not a ligature safe environment.
c) Another particular problem identified was the long waiting times for psychological assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient clinical capacity and skills mix in crisis houses
Wider context from the report “a) The Deputy Director for Mental Health at Northamptonshire Healthcare Foundation Trust said in his evidence “there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds”.
b) The Deputy Director also said that “we try to avoid supporting those waiting for an acute bed within crisis houses and continue to use out of area provisions as required and where appropriate”. However, it emerged in evidence that there are also pressures locally and nationally on the availability of out of area acute beds and that this particularly so in relation to provision for the elderly. Even if out of area beds are found, they can be a great distance away from the patient’s home address which can present difficulties including in relation to continuity of treatment. In Mr Ward’s case he was having rTMS treatment during each week day and that treatment is not available in all areas of the Country. This increases the likelihood that a crisis house may be utilised. However a crisis house does not offer the same level of clinical capacity and skills mix as a hospital environment and it is also not a ligature safe environment.
c) Another particular problem identified was the long waiting times for psychological assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient provision of acute mental health beds
Wider context from the report “a) The Deputy Director for Mental Health at Northamptonshire Healthcare Foundation Trust said in his evidence “there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds ”.
b) The Deputy Director also said that “we try to avoid supporting those waiting for an acute bed within crisis houses and continue to use out of area provisions as required and where appropriate”. However, it emerged in evidence that there are also pressures locally and nationally on the availability of out of area acute beds and that this particularly so in relation to provision for the elderly. Even if out of area beds are found, they can be a great distance away from the patient’s home address which can present difficulties including in relation to continuity of treatment. In Mr Ward’s case he was having rTMS treatment during each week day and that treatment is not available in all areas of the Country. This increases the likelihood that a crisis house may be utilised. However a crisis house does not offer the same level of clinical capacity and skills mix as a hospital environment and it is also not a ligature safe environment.
c) Another particular problem identified was the long waiting times for psychological assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of out-of-area acute beds for elderly patients
Wider context from the report “a) The Deputy Director for Mental Health at Northamptonshire Healthcare Foundation Trust said in his evidence “there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds”.
b) The Deputy Director also said that “we try to avoid supporting those waiting for an acute bed within crisis houses and continue to use out of area provisions as required and where appropriate”. However, it emerged in evidence that there are also pressures locally and nationally on the availability of out of area acute beds and that this particularly so in relation to provision for the elderly . Even if out of area beds are found, they can be a great distance away from the patient’s home address which can present difficulties including in relation to continuity of treatment. In Mr Ward’s case he was having rTMS treatment during each week day and that treatment is not available in all areas of the Country. This increases the likelihood that a crisis house may be utilised. However a crisis house does not offer the same level of clinical capacity and skills mix as a hospital environment and it is also not a ligature safe environment.
c) Another particular problem identified was the long waiting times for psychological assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in psychological assessment
Wider context from the report “a) The Deputy Director for Mental Health at Northamptonshire Healthcare Foundation Trust said in his evidence “there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds”.
b) The Deputy Director also said that “we try to avoid supporting those waiting for an acute bed within crisis houses and continue to use out of area provisions as required and where appropriate”. However, it emerged in evidence that there are also pressures locally and nationally on the availability of out of area acute beds and that this particularly so in relation to provision for the elderly. Even if out of area beds are found, they can be a great distance away from the patient’s home address which can present difficulties including in relation to continuity of treatment. In Mr Ward’s case he was having rTMS treatment during each week day and that treatment is not available in all areas of the Country. This increases the likelihood that a crisis house may be utilised. However a crisis house does not offer the same level of clinical capacity and skills mix as a hospital environment and it is also not a ligature safe environment.
c) Another particular problem identified was the long waiting times for psychological assessment .
” 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 Recruit and specially train 8,500 additional mental health workers, including to support people at risk of suicide.
Verbatim wording from the response “Finally, turning to your concerns around long waiting times to access a psychological assessment, it is unacceptable that too many people are not receiving the mental health care they need when they need it and we know that waits for mental health services are far too long. We are determined to change that. As part of our mission to build an NHS that is fit for the future and that is where when people need it, we will make sure that mental health care is delivered in the community where appropriate, close to people’s homes, through new models of care and support, so that fewer people need to go into hospital. We will also recruit an additional 8,500 mental health workers to cut waiting times and provide faster treatment which will also help ease pressure on busy mental health services. These new workers will be specially trained to support people at risk of suicide.” Source location Response from Department of Health and Social care
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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 Request an NHS England report from the relevant integrated care board on local actions to prevent recurrence.
Verbatim wording from the response “Where there are concerns about the provision provided in specific crisis houses, local ICBs and/or local authorities are best placed to address these as the organisations responsible for decisions about the provision of services in their area. I have asked NHS England to provide me with a report from the ICB detailing the local position so that I can understand what actions are being taken locally to prevent such a case from happening again.” Source location Response from Department of Health and Social care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with the NHS to maximise mental health service capacity.
Verbatim wording from the response “I am sure you will appreciate that the number of mental health inpatient beds required to support a local population is dependent on both local mental health need and the effectiveness of the whole local mental health system in providing timely access to care and supporting people to stay well in the community, therefore reducing the likelihood of an inpatient admission being necessary. I also recognise that mental health services have been under significant strain in recent years due to the rise in demand and the Department will continue to work with the NHS to maximise capacity.” Source location Response from Department of Health and Social care
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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 ICBs and authorities are responsible for arranging crisis house provision and addressing concerns about specific facilities.
Verbatim wording from the response “Local integrated care boards (ICBs) and commissioning partners such as local authorities have flexibility to decide how to arrange the provision of crisis houses and similar facilities in their local area. However, in providing this flexibility, we expect crisis house services to be designed in a way which aligns with national requirements and guidance and local structures, to ensure appropriate safeguarding processes are in place.” Source location Response from Department of Health and Social care
Open published response
17 Oct 2024 Leslie Andrew Swindells · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 9 Unclear operation of supervision for mental health assistant practitioners View source Greater difficulty assessing mental health by telephone than face to face View source Failure to identify the practitioner’s role and qualifications during mental health assessments View source Lack of professional or supervisory body membership for mental health assistant practitioners View source Poor documentation of mental health assessment content View source Insufficient mental health training for practitioners conducting mental health reviews View source Failure to restrict mental health reviews to practitioners with adequate mental health understanding View source Failure to provide competent triage and allocation of mental health appointments View source Lack of clarity among GPs about the scope of routine mental health practitioner roles View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Leslie Andrew Swindells · 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
Leslie Andrew Swindells had a complex mental health background and, after his mental health deteriorated, was found unresponsive at home with self-inflicted puncture wounds to the neck. The concerns included assessment by a practitioner with limited mental-health training, lack of appropriate triage and escalation, failure to recognise and mitigate risk, telephone-based assessment, inadequate documentation, and unclear supervision arrangements.
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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 Unclear operation of supervision for mental health assistant practitioners
Wider context from the report “4. The evidence was that where GP practices chose to deploy staff with such limited qualifications to see those who needed treatment for their mental health it was essential that all those in the practice understood the limitations of the role and that there was close supervision of the practitioner .
5. The inquest heard that it was envisaged by the practice that the GP on duty would have a supervisory role. However it was unclear how this operated other than by the mental health assistant escalating a concern to the duty GP .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Greater difficulty assessing mental health by telephone than face to face
Wider context from the report “6. The assessment was carried out by telephone. The inquest was told that approximately 80% of the practitioner’s mental health reviews took place in this way although it was accepted in evidence that it was far more challenging to assess an individual’s mental health via telephone than face to face . During the conversation the practitioner did not identify their role or their qualifications to Mr Swindells.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 the practitioner’s role and qualifications during mental health assessments
Wider context from the report “6. The assessment was carried out by telephone. The inquest was told that approximately 80% of the practitioner’s mental health reviews took place in this way although it was accepted in evidence that it was far more challenging to assess an individual’s mental health via telephone than face to face. During the conversation the practitioner did not identify their role or their qualifications to Mr Swindells .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 professional or supervisory body membership for mental health assistant practitioners
Wider context from the report “8. Practitioners such as the one who saw Mr Swindells are not part of a professional /supervisory body .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 documentation of mental health assessment content
Wider context from the report “7. The documentation of the practitioner was poor and did not reflect the content of the conversation which had been recorded and was available to the inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 mental health training for practitioners conducting mental health reviews
Wider context from the report “1. The inquest heard evidence that the practitioner who saw Mr Swindells had very limited training in mental health and was employed in a role described as a mental health assistant practitioner. The evidence was that there was limited understanding of the scope of their role by GPs and what was covered by the term routine mental health appointments.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict mental health reviews to practitioners with adequate mental health understanding
Wider context from the report “2. In Mr Swindells case the evidence was that he should never have had a review undertaken by someone with such a limited an understanding of mental health and that lack of understanding of mental health meant that the practitioner did not recognise the level of risk Mr Swindells posed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 competent triage and allocation of mental health appointments
Wider context from the report “3. The appointment had been booked via the reception team with no triage by a doctor following a telephone call to the practice. The evidence was that a shortage of trained reception/admin staff meant that an agency worker was screening calls that day and had a limited understanding of how patients needed to be allocated .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 clarity among GPs about the scope of routine mental health practitioner roles
Wider context from the report “1. The inquest heard evidence that the practitioner who saw Mr Swindells had very limited training in mental health and was employed in a role described as a mental health assistant practitioner. The evidence was that there was limited understanding of the scope of their role by GPs and what was covered by the term routine mental health appointments .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The employer must specify the assistant practitioner's role and course before NHS Workforce Training and Education can provide training-content details.
Verbatim wording from the response “Assistant practitioners in the health and care sectors undertake higher education at academic Level 5 via an apprenticeship: Assistant practitioner (health) / Institute for Apprenticeships and Technical Education. However, there are a number of roles with similar job titles, which span nursing and the allied health professions. As the employer, GTD Healthcare would therefore need to specify the role function and university course undertaken for NHS Workforce Training and Education to provide details regarding training content. It may be helpful to note that the role of the assistant practitioner is commonly renumerated at or equivalent to NHS Agenda for Change Band 4.” Source location Response from DHSC
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Concerns about care and documentation should be addressed by the provider, rather than NHS England or the CQC.
Verbatim wording from the response “Upon review, many concerns fall within the remit of the provider and their responsibility as an employer to meet the fundamental standards set out in Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” Source location Response from DHSC
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 Clinical responsibility and liability for the assistant practitioner's actions rests with the supervising GP.
Verbatim wording from the response “Practitioners such as the one who saw Mr Swindell’s are not part of a professional /supervisory body.” Source location Response from DHSC
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 Further comment on the practitioner's training or minimum role requirements is not possible without the provider identifying the role and employment arrangements.
Verbatim wording from the response “As the report raises several concerns regarding the care of those with suicidal ideation and complex mental health, Departmental officials have made enquiries with NHS England and the Care Quality Commission (CQC) to ensure we adequately address your concerns. NHS England has reviewed each of the concerns and provided relevant information / context to inform DHSC’s response. This is based on the information available. Without further information from the provider specifying the role function and the employment arrangements of the practitioner who saw Mr Swindells, we are unable to comment further on their training or any minimum role requirements.” Source location Response from DHSC
Open published response
15 Oct 2024 Stephen Charles Stringer · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Failure to maintain holistic oversight of patients receiving care from multiple practitioners View source Failure to recognise persistent hoarse voice as a potential laryngeal cancer red flag View source Failure to provide clear electronic patient enquiry routing information View source Failure to transfer administrative patient enquiries to the patient record and make them available to doctors View source Limited public awareness of voice change as a potential cancer symptom View source See 2 more concerns
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Stephen Charles Stringer · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Charles Stringer developed a hoarse voice from January 2023, but its persistence and deterioration were not recognised as a potential cancer warning sign until October 2023. He was diagnosed in January 2024 with stage 4 squamous cell carcinoma of the glottis and treated palliatively. The report identified concerns about delayed referral, gaps in electronic patient enquiry systems, fragmented oversight of his care, and limited awareness of persistent hoarseness as a possible cancer symptom.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain holistic oversight of patients receiving care from multiple practitioners
Wider context from the report “3. A number of different health professionals had input into his care. This meant that there was no one health professional who had a good insight into his overall deterioration and symptoms. Where multiple practitioners were involved one person needed to maintain oversight or the electronic patient record needed to have easily accessible clear action plans and notes were required so that a patient and their symptoms could be seen holistically rather than a one off.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise persistent hoarse voice as a potential laryngeal cancer red flag
Wider context from the report “2. The evidence from the ENT consultant was that it was important that where a patient presented with a hoarse voice that all health professionals explored for how long it had been an issue and whether there was a realistic treatable cause for it .In the absence of any clear cause such as a throat infection or where there was no clear response to treatment then a hoarse voice should be seen as a red flag symptom for laryngeal cancers and result in a referral on the 2 week wait. It was clear from the evidence at the inquest that unlike other cancer red flags such as blood in urine the significance of a persistent hoarse voice was not recognised by a number of different healthcare professionals who saw him.
The inquest was told that early detection of laryngeal cancers through early referrals on the 2 week wait significantly improves the outcomes for patients because far more treatment options are open to clinicians.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 clear electronic patient enquiry routing information
Wider context from the report “1. The inquest heard evidence that the GP practice had in accordance with the local requirements introduced an electronic patient enquiry service alongside a telephone service. Patients contacting the surgery had to select which stream within the practice their enquiry went to. It was not always clear from the headings whether the query would be seen by a GP or the admin team. Information that went into the admin work stream from a patient did not go onto the patient record and was not seen by a doctor.
The GPs at the practice were unaware of this and patients had no way of knowing that the information they had sent in was not in the patient record. The practice involved in this inquest had taken steps since identifying the issue to mitigate the risks. However the evidence before the inquest was that the software in question was widely used by GP practices within Derbyshire and nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer administrative patient enquiries to the patient record and make them available to doctors
Wider context from the report “1. The inquest heard evidence that the GP practice had in accordance with the local requirements introduced an electronic patient enquiry service alongside a telephone service. Patients contacting the surgery had to select which stream within the practice their enquiry went to. It was not always clear from the headings whether the query would be seen by a GP or the admin team. Information that went into the admin work stream from a patient did not go onto the patient record and was not seen by a doctor.
The GPs at the practice were unaware of this and patients had no way of knowing that the information they had sent in was not in the patient record. The practice involved in this inquest had taken steps since identifying the issue to mitigate the risks. However the evidence before the inquest was that the software in question was widely used by GP practices within Derbyshire and nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Limited public awareness of voice change as a potential cancer symptom
Wider context from the report “4. There was also evidence that there is limited public awareness of how significant a change in voice can be and recognising it as a potential cancer symptom. Greater public awareness of symptoms of laryngeal cancers would ensure the public were better placed to seek help at an early stage.
” 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 Individual general practices, rather than the department, are responsible for maintaining reliable patient-interaction and care-navigation systems.
Verbatim wording from the response “General practices are independent businesses who are contracted by NHS commissioners to perform medical services, and it is the responsibility of the individual practice (provider) to have reliable systems in place to manage interactions with patients. It is essential that clinical issues mistakenly categorized as administrative are identified and appropriately” Source location Response from DHSC
Open published response
Concerns raised 2 Failure to include corridor patient care areas in the Emergency Department nursing staffing template View source Failure to provide sufficient designated clinical space for Emergency Department patients 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
Tamara DAVIS · 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
Tamara Davis attended hospital after being unwell for five days and was treated for suspected chest infection before deteriorating and dying on 13 December 2022 from multi-organ failure associated with bronchopneumonia caused by Influenza A infection. A substantive concern was the use of an overcrowded Emergency Department corridor for patient care, where patients lacked privacy, toilet facilities and confidentiality, and where the area was not designated as a clinical area or included in the nursing staffing template.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to include corridor patient care areas in the Emergency Department nursing staffing template
Wider context from the report “During the inquest I heard evidence from clinicians at University Hospitals Sussex NHS Foundation Trust that when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved and treated in the corridor as there was no clinical area available to do so. The area is not designated as a clinical area and is not included within the Nursing staffing template for the ED . When Ms Davis was treated in the Royal Sussex County Hospital, Brighton on 11 December 2022 there were, at times, more than 20 patients in that area.
Clinicians from University Hospitals Sussex NHS Foundation Trust gave evidence as to the action that is being taken by the Trust currently to (1) reduce the number of patients who are sent to the Emergency Department who could be seen by other services in the community and (2) to create an improved patient flow through the Royal Sussex County Hospital. The evidence was however that, despite these actions, the corridor remains in use for patients currently as there is insufficient space within the department to care for patients. There was no evidence as to when, and if, this practice would no longer be necessary.
I heard that the provision of care in the ED corridor meant that patients lacked privacy, toilet facilities and confidentiality. I understood from the evidence of the clinicians that they were concerned that patients were being moved into the Corridor but there appeared to be no other option when the Emergency Department exceeds capacity. I heard that in the event of a major incident University Hospitals Sussex NHS Foundation Trust would have to clear the Emergency Department, as they had done on occasion, as this would be the only way to create the necessary clinical space when the department was already over capacity and using the corridor.
I was also advised that the use of corridors to care for patients is not only an issue at the Royal Sussex County Hospital, Brighton but is used throughout the country when the capacities of Emergency Departments has been reached and there is nowhere to move patients to.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 sufficient designated clinical space for Emergency Department patients
Wider context from the report “During the inquest I heard evidence from clinicians at University Hospitals Sussex NHS Foundation Trust that when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved and treated in the corridor as there was no clinical area available to do so . The area is not designated as a clinical area and is not included within the Nursing staffing template for the ED. When Ms Davis was treated in the Royal Sussex County Hospital, Brighton on 11 December 2022 there were, at times, more than 20 patients in that area.
Clinicians from University Hospitals Sussex NHS Foundation Trust gave evidence as to the action that is being taken by the Trust currently to (1) reduce the number of patients who are sent to the Emergency Department who could be seen by other services in the community and (2) to create an improved patient flow through the Royal Sussex County Hospital. The evidence was however that, despite these actions, the corridor remains in use for patients currently as there is insufficient space within the department to care for patients . There was no evidence as to when, and if, this practice would no longer be necessary.
I heard that the provision of care in the ED corridor meant that patients lacked privacy, toilet facilities and confidentiality . I understood from the evidence of the clinicians that they were concerned that patients were being moved into the Corridor but there appeared to be no other option when the Emergency Department exceeds capacity. I heard that in the event of a major incident University Hospitals Sussex NHS Foundation Trust would have to clear the Emergency Department, as they had done on occasion, as this would be the only way to create the necessary clinical space when the department was already over capacity and using the corridor.
I was also advised that the use of corridors to care for patients is not only an issue at the Royal Sussex County Hospital, Brighton but is used throughout the country when the capacities of Emergency Departments has been reached and there is nowhere to move patients to.
” 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 NHS England is best placed to address local urgent and emergency care performance and RSCH’s mitigation of temporary escalation space use.
Verbatim wording from the response “The report raises concerns over emergency department capacity, poor patient flow and the use of corridor care at Royal Sussex County Hospital (RSCH) and nationally. I understand that your report and matters of concerns have also been sent to NHS England, and they are best placed to respond with the specific actions being taken locally to improve urgent and emergency care performance at RSCH.” Source location Response from DHSC
Open published response
14 Oct 2024 Mia Louise Gauci-Lamport · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 11 Lack of specialist NHS paediatric neuro-consultant oversight View source Failure to maintain comprehensive, understandable, accurate and contemporaneous medical records View source Failure to undertake regular Paediatric Early Warning Score assessments View source Deficiencies in ongoing staff training View source Deficient clinical governance of management and investigation View source Failure to conduct regular audits of clinical practice View source Failure to provide sufficiently frequent direct night-time visual observations View source Failure to ensure robust procedures are in place View source Delays in fulfilling Duty of Candour obligations View source Failure to undertake regular multidisciplinary clinical reviews View source Lack of regular independent consultant oversight and coordination of investigations and multidisciplinary management View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mia Louise Gauci-Lamport · 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
Mia Louise Gauci-Lamport, who had treatment-resistant epilepsy and required full-time residential care, was found cyanotic and unresponsive at around 06.32 hours on 11 September 2023 after not being visually checked when a carer entered her room. Resuscitation was unsuccessful. The report raised concerns about inadequate night-time monitoring, incomplete medical records and insufficient clinical oversight and governance.
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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 specialist NHS paediatric neuro-consultant oversight
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented.
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs.
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain comprehensive, understandable, accurate and contemporaneous medical records
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented .
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs.
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 regular Paediatric Early Warning Score assessments
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented.
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs.
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in ongoing staff training
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations, ongoing staff training , ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Deficient clinical governance of management and investigation
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death , delay in fulfilling the Duty of Candour’ obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct regular audits of clinical practice
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice . These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 sufficiently frequent direct night-time visual observations
Wider context from the report “1. Lack of appropriate monitoring of Mia during the night :
Mia’s underlying illness caused seizures which were multifocal, complex and variable from tonic-clonic, myoclonic to cluster and absence seizures. Her care plan stipulated that carers should enter her room every 15 minutes to undertake visual observations throughout the night to ensure Mia was in a safe position, was breathing and not at risk of asphyxiation. However, this did not take place as frequently as specified . Moreover, it was common practice amongst some carers to review images from a video monitor placed over Mia’s cot rather than direct visualisation despite it being recognised that the monitor was insufficiently sensitive to reassure the carer that Mia was breathing, seizure free and safe from asphyxiation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 robust procedures are in place
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 fulfilling Duty of Candour obligations
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations , ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 regular multidisciplinary clinical reviews
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented.
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs .
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of regular independent consultant oversight and coordination of investigations and multidisciplinary management
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented.
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs.
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” 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 Consider duty-of-candour review findings alongside manager-regulation consultation findings while developing healthcare candour policy.
Verbatim wording from the response “In relation to your point about the delay in fulfilling the duty of candour obligations, as you may be aware, the statutory duty of candour (organisational) places a direct obligation upon NHS trusts and all other health and social care providers registered with the CQC to be open and honest with patients, service users and their families, when a notifiable safety incident occurs. The Government is supportive of the review on the duty it inherited from the previous administration and will consider the findings, recently published on 26 November, following a call for evidence in April this year. The government will consider these findings alongside findings from the ongoing manager regulation consultation as it continues to develop policy on candour in healthcare.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Local Authority, not NHS England, is responsible for overseeing the quality of the residential care service because it commissioned the bed.
Verbatim wording from the response “Mia was in a residential care bed, which is commissioned instead by the Local Authority. The commissioning body, in this case the LA, has the responsibility for oversight of the quality of the service. NHSE have provided assurance that their regional team has been working with system and other partners on responding to risks and concerns in a joint approach at this provider, which will be set out in their response. In case of interest, NHSE’s guidance on specialised services can be found here: NHS commissioning » Specialised services.” Source location Response from DHSC
Open published response
9 Oct 2024 Nigel Hutton HAMMOND · Prevention of Future Deaths report Suffolk
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Concerns raised 1 Failure to enable AMHPs to make direct referrals to the emergency Crisis Resolution and Home Treatment Team View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Nigel Hutton HAMMOND · 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
Nigel Hammond died at Addenbrooke’s Hospital on 14 March 2024, three days after falling from a window at home and sustaining serious injuries. The inquest concluded that the death was suicide while the balance of his mind was disturbed. The principal concern was that the AMHP could not directly refer Nigel to the Crisis Resolution and Home Treatment Team, and that this may have delayed support before his fatal fall.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to enable AMHPs to make direct referrals to the emergency Crisis Resolution and Home Treatment Team
Wider context from the report “7. That said, although Nigel did not meet the criteria for immediate admission, the AMHP believed Nigel was mentally very unwell, and in need of immediate support. The court heard that such support would be available within a 4-hour target time, from the emergency Crisis Resolution and Home Treatment Team.
8. However, the court was told that an AMHP, despite their role in the coordination of the mental health assessment and admission to hospital of a patient, were not permitted to make direct referrals to the emergency Crisis Resolution and Home Treatment Team .
9. The court heard that the normal route for such referrals was via the GP Surgery, or primary care Mental Health Nurse, neither of whom in Nigel’s case would have been available before 08:00 on Monday 11th March 2024 . Nigel’s fall which led to his death, occurred at 06:25 that morning.
10. I am concerned, as had the AMHP in Nigel’s case been able to directly refer him to the Crisis Resolution and Home Treatment Team on the 9th March 2024, mental health professionals would have attended , and been able to provide additional support, advice and potentially additional treatment for Nigel, in all likelihood preventing his death.
” Open source report
Concerns raised 4 Extremely limited doctor training on ME/CFS treatment, especially severe ME View source Lack of specialist healthcare provision for patients with severe ME View source Failure of NICE guidance to provide detailed guidance on managing severe ME at home or in the community View source Lack of current funding for ME/CFS treatment research and understanding of causes View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Maeve Boothby O’Neill · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Maeve Boothby O’Neill, who had severe ME and was bedbound, died at home on 3 October 2021 after three hospital admissions during 2021. The report identified concerns about the lack of specialist care provision for severe ME, limited research funding and medical training, and insufficient guidance on managing severe ME in the home or community, including nutritional support.
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 Extremely limited doctor training on ME/CFS treatment, especially severe ME
Wider context from the report “(3) During the course of the inquest it became clear that there was extremely limited training for Doctors on ME/ CFS and how to treat it – especially in relation to severe ME .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 specialist healthcare provision for patients with severe ME
Wider context from the report “(1) During the course of the evidence it became clear that there were no specialist hospitals or hospices, beds, wards or other health care provision in England for patients with severe Myalgic encephalopathies (ME) . This meant that the Royal Devon and Exeter Hospital had no commissioned service to treat Maeve and patients like her .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 NICE guidance to provide detailed guidance on managing severe ME at home or in the community
Wider context from the report “(4 ) During the course of the inquest it became clear that the 2021 NICE guidelines on ME did not provide any detailed guidance at all on how severe ME should be managed at home or in the community and in particular whether or not there is any necessary adaptation needed to the 2017 guidance on Nutrition support for adults : oral nutrition support , enteral tube feeding and parenteral nutrition .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 current funding for ME/CFS treatment research and understanding of causes
Wider context from the report “(2) During the course of the inquest it became clear that there was no current available funding for the research and development of treatment and further learning for understanding the causes of ME / Chronic Fatigue Syndrome (CFS) .
” 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 Develop an e-learning course on ME/CFS for healthcare professionals with NHS England.
Verbatim wording from the response “In relation to the issue of training for doctors on ME/CFS and how to treat it, especially in relation to severe ME/CFS, the Department is working with NHS England to develop an e-learning course on ME/CFS for healthcare professionals, with the aim of supporting staff to” Source location Response from DHSC and NIHR
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the ME/CFS community to identify opportunities to increase research.
Verbatim wording from the response “The Government is aware of the devastating effect ME/CFS can have on those suffering from the condition and recognises that it is an under-researched area. Unfortunately, despite our efforts to stimulate high-quality research in this area, we have received a low number of research applications on ME/CFS. We will, however, continue to work with the community, to identify new opportunities to increase research in this area.” Source location Response from DHSC and NIHR
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fund high-quality ME/CFS research through national research funding programmes.
Verbatim wording from the response “On the issue of funding for research and development of treatment and further learning for understanding the causes of ME/ CFS, it is not accurate to say that there is no funding available. The Government is committed to funding high-quality research to understand the causes, consequences and treatment of ME/CFS, and is actively exploring next steps for research in this area. Government research funding is currently available for ME/CFS through the National Institute for Health and Care Research (NIHR) and UK Research and Innovation.” Source location Response from DHSC and NIHR
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 It is inaccurate to say that no funding is available for ME/CFS research and treatment development.
Verbatim wording from the response “On the issue of funding for research and development of treatment and further learning for understanding the causes of ME/ CFS, it is not accurate to say that there is no funding available. The Government is committed to funding high-quality research to understand the causes, consequences and treatment of ME/CFS, and is actively exploring next steps for research in this area. Government research funding is currently available for ME/CFS through the National Institute for Health and Care Research (NIHR) and UK Research and Innovation.” Source location Response from DHSC and NIHR
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England, NICE and the Medical Schools Council will address concerns falling within their respective areas of competence.
Verbatim wording from the response “In preparing this response, DHSC officials have liaised with NHS England, NICE and the Medical Schools Council to ensure a comprehensive approach to fully addressing your” Source location Response from DHSC and NIHR
Open published response
7 Oct 2024 John Raymond EYRE · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 2 Lack of national guidance or policy on returning prisoners to custodial settings when prison healthcare concerns have not been considered by the consultant View source Lack of a concrete escalation route for prison healthcare staff challenging the appropriateness and sustainability of acute-setting discharge 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
John Raymond EYRE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Raymond Eyre was a serving prisoner whose health deteriorated in 2022, including recurrent neutropenic sepsis, and he died in hospital on 20 November 2022 from pneumonia, with liver disease also recorded. Concerns included the lack of a concrete escalation route when prison healthcare staff challenged his discharge and the absence of national guidance on returning a prisoner to custody when those concerns had not been considered by the consultant.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance or policy on returning prisoners to custodial settings when prison healthcare concerns have not been considered by the consultant
Wider context from the report “(2) There was no national guidance document, or national policy in place, which outlined whether a prisoner should be returned to a custodial setting in the absence of the prison healthcare provider's concerns being considered by the patient's consultant.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 concrete escalation route for prison healthcare staff challenging the appropriateness and sustainability of acute-setting discharge
Wider context from the report “(1) There was no concrete escalation route when prison healthcare staff challenged the appropriateness and sustainability of discharge from the acute setting.
” 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 Ask officials to consider whether hospital discharge guidance should explicitly require consideration of care-provider concerns before discharge to custodial settings.
Verbatim wording from the response “As set out in the Hospital Discharge and Community Support Guidance (January 2024), NHS bodies should work closely with care providers and other partners to ensure people’s care is timely, optimal and co-ordinated, while also practising active risk management to reach a reasonable balance between safety and minimising delays when patients are ready to be discharged. I will ask my officials to consider whether an amendment to the hospital discharge guidance is required to make more explicit the obligation to consider concerns raised by care providers before the discharge of patients to custodial settings. Furthermore, as required and described in the Health and Social Care Act 2012, patients within secure settings should receive the same quality and access of healthcare as the rest of the population, both in terms of the range of interventions to meet their needs, and the quality” Source location Response from DHSC
Open published response
Concerns raised 8 Inadequate primary healthcare support for discharges View source Lack of control over services primarily responsible for ambulance delays View source Inadequate community hospital provision for discharges View source Lack of single-organisation responsibility for ensuring sufficient social care provision View source Lack of overarching responsibility for patient safety risks from ambulance delays View source Continuing delays in ambulance handover and response View source Inadequate social care provision for discharges View source Failure of average performance measures to reveal spikes in ambulance handover and response delays View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Kevin George Woods · 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
Kevin George Woods died on 17 January 2024 after suffering cardiac arrest following a prolonged ambulance delay when no Category 2 ambulance was available. The inquest found that he had an undiagnosed and possibly treatable heart condition and that the delay denied him potentially lifesaving treatment. The principal concerns were continuing ambulance and hospital handover delays, inadequate social care and community healthcare provision contributing to delayed discharges, and the absence of a single organisation responsible for managing the associated patient-safety risks.
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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 Inadequate primary healthcare support for discharges
Wider context from the report “2) There is a direct connection between the risk of ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support for discharges in Cornwall. This is because the inadequacies in these services lead to delayed discharges causing crowding in ED, shortage of beds in acute wards, and handover delays. This creates a risk of future systemic failures causing ambulance delays.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 control over services primarily responsible for ambulance delays
Wider context from the report “4) There is an absence of any overarching organisation with responsibility for patient safety risk from ambulance delays. The organisations immediately required to deal with ambulance delays do not have control over the services primarily responsible for the delays.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 community hospital provision for discharges
Wider context from the report “2) There is a direct connection between the risk of ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support for discharges in Cornwall. This is because the inadequacies in these services lead to delayed discharges causing crowding in ED, shortage of beds in acute wards, and handover delays. This creates a risk of future systemic failures causing ambulance delays.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 single-organisation responsibility for ensuring sufficient social care provision
Wider context from the report “3) There is no single organisation with responsibility to ensure that the provision of social care is sufficient to avoid delayed discharges leading to ambulance delays. The obligation upon local authorities such as Cornwall Council is limited to a requirement to promote the market.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 overarching responsibility for patient safety risks from ambulance delays
Wider context from the report “4) There is an absence of any overarching organisation with responsibility for patient safety risk from ambulance delays. The organisations immediately required to deal with ambulance delays do not have control over the services primarily responsible for the delays.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Continuing delays in ambulance handover and response
Wider context from the report “1) Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 social care provision for discharges
Wider context from the report “2) There is a direct connection between the risk of ambulance delays and inadequate social care provision , community hospital provision and primary healthcare support for discharges in Cornwall. This is because the inadequacies in these services lead to delayed discharges causing crowding in ED, shortage of beds in acute wards, and handover delays. This creates a risk of future systemic failures causing ambulance delays.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 average performance measures to reveal spikes in ambulance handover and response delays
Wider context from the report “1) Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality.
” 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 Return to the NHS Constitution’s safe operational waiting-time standards.
Verbatim wording from the response “At a national level, this government is committed to returning to the safe operational waiting time standards set out in the NHS Constitution. In doing so we will be honest about the challenges facing the health service and serious about tackling them. The Health Secretary ordered an independent investigation of NHS performance to provide an assessment of the issues and challenges it faces. This reported on 12th September 2024 and the investigation’s findings will feed into the government’s work on a 10-year plan to radically reform the NHS and build a health service that is fit for the future.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop local NHS and social-care partnerships and support arrangements to reduce delayed discharges and enable patients to return home sooner.
Verbatim wording from the response “This government is working to improve hospital flow to make sure people do not spend longer than necessary in hospital and reduce delayed discharges. We will tackle delayed discharges by developing local partnership working between the NHS and social care and making sure people get the right support from health and social care services to return home as soon as possible.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work directly with health and social-care partners in integrated care systems experiencing the greatest discharge delays to drive improvements.
Verbatim wording from the response “We have also ensured that every acute hospital has access to a care transfer hub. These hubs bring together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support. In the integrated care systems that face the most discharge delays, the Department is working directly with partners across health and social care to drive improvements.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure every acute hospital has access to a care transfer hub for complex discharges.
Verbatim wording from the response “We have also ensured that every acute hospital has access to a care transfer hub. These hubs bring together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support. In the integrated care systems that face the most discharge delays, the Department is working directly with partners across health and social care to drive improvements.” Source location Response from DHSC
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 Healthcare providers are responsible for identifying and mitigating risks within their services through their own patient-safety processes.
Verbatim wording from the response “The responsibility for identifying and mitigating risks within healthcare services sits with the provider of those services. Each provider of NHS services will have their own internal processes and structures for the identification, examination, management and improvement of patient safety risks. The Care Quality Commission (CQC) is responsible for monitoring the quality and safety of the care provided by NHS Trusts through the regulation of the Trust’s regulated activities. The CQC carries out inspections and produces reports setting out their findings.” Source location Response from DHSC
Open published response
3 Oct 2024 John Turner · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Reduced scope for identifying atypically presenting major or life-threatening illness in Emergency Departments View source Delays in recording senior clinical findings in the electronic patient record View source Failure to follow the Manchester Triage System during high demand View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John Turner · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Turner died at Tameside General Hospital on 23 August 2023 from a pulmonary embolism due to a deep vein thrombosis, neither of which had been identified when he attended the Emergency Department three days earlier. The concerns included significant deviation from the Manchester Triage System, a requested D-Dimer test not being undertaken, delayed recording of a senior doctor’s findings, and reduced scope to identify atypical major or life-threatening illness during periods of unremitting demand.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Reduced scope for identifying atypically presenting major or life-threatening illness in Emergency Departments
Wider context from the report “In the present case, the court heard evidence as to significant deviation (which can particularly occur at times of high demand) from the Manchester Triage System which seeks to safely manage patient flow with reference to competing needs.
In addition, it was almost 8 hours before the senior doctor who reviewed Mr Turner on 20th August 2023 recorded her findings in the electronic patient record, in all likelihood reflecting competing clinical demands on her time.
In the light of the above, I am concerned, as a practical consequence of unremitting demand on this and other Emergency Departments, the scope for identifying major or life-threatening illness which presents atypically is significantly reduced .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 recording senior clinical findings in the electronic patient record
Wider context from the report “In the present case, the court heard evidence as to significant deviation (which can particularly occur at times of high demand) from the Manchester Triage System which seeks to safely manage patient flow with reference to competing needs.
In addition, it was almost 8 hours before the senior doctor who reviewed Mr Turner on 20th August 2023 recorded her findings in the electronic patient record , in all likelihood reflecting competing clinical demands on her time.
In the light of the above, I am concerned, as a practical consequence of unremitting demand on this and other Emergency Departments, the scope for identifying major or life-threatening illness which presents atypically is significantly reduced.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the Manchester Triage System during high demand
Wider context from the report “In the present case, the court heard evidence as to significant deviation (which can particularly occur at times of high demand) from the Manchester Triage System which seeks to safely manage patient flow with reference to competing needs .
In addition, it was almost 8 hours before the senior doctor who reviewed Mr Turner on 20th August 2023 recorded her findings in the electronic patient record, in all likelihood reflecting competing clinical demands on her time.
In the light of the above, I am concerned, as a practical consequence of unremitting demand on this and other Emergency Departments, the scope for identifying major or life-threatening illness which presents atypically is significantly reduced.
” Open source report
2 Oct 2024 Michael Sean Heath · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to ensure carers are informed of Mental Health Act admissions within 24 hours View source Failure to establish agreed communication means and maintain relevant patient information in an accessible central repository View source Failure to provide mental health patients with access to an independent mental health advocate View source Failure to ensure officers are trained to assess mental health-related calls and associated immediate risks View source Failure to determine when police are the appropriate agency for mental health-related enquiries View source Lack of connectivity between overseas and UK mental health services during repatriation of an ill patient View source Failure to consider wider circumstances and likely follow-on care before removing out-of-area patients from GP practice lists 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
Michael Sean Heath · 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
Michael Sean Heath died on 25 August 2023 in an apartment from injuries involving his pericardial sac. The inquest jury determined that he died by taking his own life while suffering an acute mental health crisis. Principal concerns included police and mental health service responses, inter-agency communication, continuity of care after his return from Gibraltar, and access to appropriate mental health support.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure carers are informed of Mental Health Act admissions within 24 hours
Wider context from the report “In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to establish agreed communication means and maintain relevant patient information in an accessible central repository
Wider context from the report “The means of communication is known and agreed between all mental health agencies to ensure all relevant patient information is held in an accessible central repository .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 mental health patients with access to an independent mental health advocate
Wider context from the report “In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 officers are trained to assess mental health-related calls and associated immediate risks
Wider context from the report “In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature , the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mental health related enquiries due to their powers of entry;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 determine when police are the appropriate agency for mental health-related enquiries
Wider context from the report “In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature, the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mental health related enquiries due to their powers of entry ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 connectivity between overseas and UK mental health services during repatriation of an ill patient
Wider context from the report “The apparent lack of connectivity between mental health services abroad and the UK upon repatriation whilst the patient remains 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 Failure to consider wider circumstances and likely follow-on care before removing out-of-area patients from GP practice lists
Wider context from the report “That there is a risk to patients generated by a decision to remove a patient from a GP practice list where the patient resides out of geographical area for that GP practice without considering the wider circumstances and the likely follow on care ; and
” 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 Introduce an opt-out independent mental health advocacy process under which advocates interview detained patients about using advocacy services.
Verbatim wording from the response “As you have highlighted, access to independent advocacy support is also very important. Detained patients do have the right to an independent mental health advocate (IMHA) and should be informed of this right by the hospital manager. Under the Mental Health Bill, IMHA services will operate on an opt out process in which detained patients will be interviewed by an IMHA to decide whether they would like to make use of their services. This takes the onus away from the patient having to ask for a referral themselves and instead places this on the hospital and advocacy services to provide this for patients. We expect that this will improve patient rights and access to advocacy services.” Source location Response from DHSC
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 Communication arrangements between mental-health agencies should be established locally by Greater Manchester and other local bodies.
Verbatim wording from the response “You have also raised concerns around ensuring that means of communication are known and agreed between all mental health agencies to ensure relevant patient information is held in an accessible central repository. Communication arrangements should be established locally at system level, so the Greater Manchester Mental Health NHS Foundation Trust and the other local bodies to whom you have sent your report should be able to provide further information about local arrangements in this case.” Source location Response from DHSC
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 Mental-health repatriation is not provided for by the Mental Health Act and presents infeasible data-protection, language and logistical challenges.
Verbatim wording from the response “You have also raised concerns around a lack of connectivity between mental health services abroad and the UK upon repatriation to the UK. I should explain that the Mental Health Act does not include provision for repatriation of individuals back to the UK (other than in certain cases where individuals have been diverted from the justice system to the hospital system by an order of a court following a criminal offence). This would present a number of challenges in terms of data protection, language and logistical practicalities which would not be feasible.” Source location Response from DHSC
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 Police mental-health call training is assigned to the Home Office, Greater Manchester Police and the College of Policing.
Verbatim wording from the response “With regard to your concern around training for police officers in dealing with calls of a mental health nature, I would expect this to be addressed by the Home Office, Greater Manchester Police and the College of Policing in their responses to you, as policing and police training falls under their remit.” Source location Response from DHSC
Open published response
1 Oct 2024 Ryan James Richard Campbell · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of a full suite of cardiac diagnostic imaging equipment at Stepping Hill Hospital View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ryan James Richard Campbell · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ryan Campbell experienced persistent chest pain and underwent medical investigations, but further cardiac imaging was still awaited when he died. The report identified delays associated with the absence of a full suite of cardiac diagnostic imaging equipment at Stepping Hill Hospital, particularly CT or MR angiograms, and the need to switch treatment centres.
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 full suite of cardiac diagnostic imaging equipment at Stepping Hill Hospital
Wider context from the report “The absence of a full suite of cardiac diagnostic imaging equipment at Stepping Hill Hospital, particularly CT or MR angiograms , contributes to delays in diagnosis for patients and the risk of delays is heightened by having to switch treatment centres. This lack of a range of equipment is inconsistent with providing a full cardiology service to patients .
” 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 trust and NHS England are responsible for procuring diagnostic equipment and are better positioned to address the issue.
Verbatim wording from the response “The Department has reviewed the concerns outlined in the report. As the procurement of diagnostic equipment at Stockport NHS Foundation Trust falls under the responsibility of the trust and NHS England (NHSE), we have determined that they are better positioned to address the issue and provide an appropriate response. Since NHSE are also a named recipient in the report, we have engaged with them, and they have confirmed receipt of the report and are working on their response.” Source location Response from DHSC
Open published response
24 Sep 2024 George Neville Coulthard · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Delays in identifying suitable care home placements View source Limited access to tissue viability and district nursing information and support for wound care in the community View source Lack of effective communication about the required care pathway between discharging and community teams View source Failure of management teams to clarify the required level and type of care View source Unavailability of acute beds causing delays in allocating beds to patients requiring admission View source Failure to ensure internal care documentation reflects the correct care position View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
George Neville Coulthard · 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
George Neville Coulthard sustained skin wounds after an accidental fall, experienced gastrointestinal bleeds while in hospital, and later deteriorated and died at Bramhall Manor on 27 January 2024. The principal concerns were delays in discharge due to difficulty finding a suitable care home, ineffective communication about whether he required end-of-life care or rehabilitation, failure to clarify care arrangements, and limited community access to wound-care support.
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 identifying suitable care home placements
Wider context from the report “1. Mr Coulthard was assessed as being suitable for discharge on 18th December. He remained in an acute hospital setting for a further 4 weeks due to challenges in identifying a suitable care home . This was due to the inquest was told to a shortage of suitable places and the Christmas period. The impact of this on Mr Coulthard was that he remained in an acute setting when the inquest was told the care he required would have been better delivered in a care home /nursing home setting.
In addition the inquest heard evidence that it meant that an acute bed required for other patients was not available creating delays in allocating beds to patients requiring admission. The inquest was told that significant delays of this nature occur on a regular basis and are often exacerbated over the Christmas period.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Limited access to tissue viability and district nursing information and support for wound care in the community
Wider context from the report “4. The evidence before the inquest was that whilst in the community prior to his final hospital admission the access to information and support, from tissue viability and district nursing teams, to care for and treat his wounds was very limited . Better access to wound care would have reduced the risk of further wound deterioration in the community and reduced the risk of him requiring inpatient care for his wounds. However the demands across GM on TVN and DN services made this difficult to achieve .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of effective communication about the required care pathway between discharging and community teams
Wider context from the report “2. The lack of effective communication between the discharging team and the community teams meant that it was not understood if Mr Coulthard was on End of Life Care or for rehabilitation . The staff at the first home treated him as an end of life patient / palliative care patient as a consequence even though the paperwork suggested he may be a discharge to assess patient. As a consequence he was moved to another care home for rehabilitation although the evidence was that there was little purpose in the transfer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 management teams to clarify the required level and type of care
Wider context from the report “3. The inquest also heard evidence that the staff at the care home had queried what level and type of care was to be delivered to Mr Coulthard given his overall presentation. However there was no evidence that the management team had sought to clarify the position or ensure the internal documentation reflected the correct position.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 acute beds causing delays in allocating beds to patients requiring admission
Wider context from the report “1. Mr Coulthard was assessed as being suitable for discharge on 18th December. He remained in an acute hospital setting for a further 4 weeks due to challenges in identifying a suitable care home. This was due to the inquest was told to a shortage of suitable places and the Christmas period. The impact of this on Mr Coulthard was that he remained in an acute setting when the inquest was told the care he required would have been better delivered in a care home /nursing home setting.
In addition the inquest heard evidence that it meant that an acute bed required for other patients was not available creating delays in allocating beds to patients requiring admission . The inquest was told that significant delays of this nature occur on a regular basis and are often exacerbated over the Christmas period.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure internal care documentation reflects the correct care position
Wider context from the report “3. The inquest also heard evidence that the staff at the care home had queried what level and type of care was to be delivered to Mr Coulthard given his overall presentation. However there was no evidence that the management team had sought to clarify the position or ensure the internal documentation reflected the correct position .
” 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 Update statutory hospital-discharge guidance to support safe, coordinated transfers and continuity of care.
Verbatim wording from the response “This funding is pooled via the Better Care Fund, which requires integrated care boards (ICBs) and local authorities to make joint plans and pool budgets for the purposes of providing more joined-up and effective care. Every acute hospital has access to a care transfer hub. These hubs bring together professionals from the NHS and social care to manage discharges for people with more complex needs and who need extra support. Statutory guidance on hospital discharge (updated in January 2024) sets out how local authorities and NHS bodies can ensure that people are discharged safely from hospital to the most appropriate place and continue to receive the care and support they need, taking into account the legal duties in the Health and Care Act 2022.” Source location Response from DHSC
Open published response
Concerns raised 6 Inadequate community hospital provision for discharges View source Inadequate social care provision for discharges View source Lack of overarching responsibility for patient safety risk from ambulance delays View source Lack of single-organisation responsibility for sufficient social care provision View source Lack of organisational control over services primarily responsible for ambulance delays View source Inadequate primary healthcare support for discharges View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
DENNIS RICHARD HARRY · 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
Dennis Richard Harry died at Royal Cornwall Hospital on 10 January 2023 from heart disease and Covid-19 infection following an 18-hour-and-50-minute ambulance delay, including delays in response and hospital handover. The report identified systemic concerns about inadequate social care, community hospital provision and primary healthcare support contributing to delayed discharges, ambulance delays and emergency department crowding. It also identified no single organisation with responsibility for ensuring sufficient social care provision or overseeing patient safety risks from ambulance delays.
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 community hospital provision for discharges
Wider context from the report “1) There is a direct connection between the risk of excessive ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support for discharges in Cornwall. This is because the inadequacies in these services lead to delayed discharges causing crowding in ED and handover delays . This creates a risk of future systemic failures causing excessive ambulance delays.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 social care provision for discharges
Wider context from the report “1) There is a direct connection between the risk of excessive ambulance delays and inadequate social care provision , community hospital provision and primary healthcare support for discharges in Cornwall. This is because the inadequacies in these services lead to delayed discharges causing crowding in ED and handover delays . This creates a risk of future systemic failures causing excessive ambulance delays.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 overarching responsibility for patient safety risk from ambulance delays
Wider context from the report “3) There is an absence of any overarching organisation with responsibility for patient safety risk from ambulance delays . The organisations immediately required to deal with ambulance delays do not have control over the services primarily responsible for the delays.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 single-organisation responsibility for sufficient social care provision
Wider context from the report “2) There is no single organisation with responsibility to ensure that the provision of social care is sufficient to avoid delayed discharges leading to ambulance delays . The obligation upon local authorities such as Cornwall Council is limited to a requirement to promote the market.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 organisational control over services primarily responsible for ambulance delays
Wider context from the report “3) There is an absence of any overarching organisation with responsibility for patient safety risk from ambulance delays. The organisations immediately required to deal with ambulance delays do not have control over the services primarily responsible for the delays .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 primary healthcare support for discharges
Wider context from the report “1) There is a direct connection between the risk of excessive ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support for discharges in Cornwall. This is because the inadequacies in these services lead to delayed discharges causing crowding in ED and handover delays . This creates a risk of future systemic failures causing excessive ambulance delays.
” 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 Ensure every acute hospital has access to a care transfer hub for complex discharges.
Verbatim wording from the response “We have also ensured that every acute hospital has access to a care transfer hub. These hubs bring together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support. In the integrated care systems that face the most discharge delays, the Department is working directly with partners across health and social care to drive improvements.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work directly with health and social-care partners in integrated care systems experiencing the greatest discharge delays to drive improvements.
Verbatim wording from the response “We have also ensured that every acute hospital has access to a care transfer hub. These hubs bring together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support. In the integrated care systems that face the most discharge delays, the Department is working directly with partners across health and social care to drive improvements.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop local NHS and social-care partnerships and coordinate support to reduce delayed discharges and enable timely returns home.
Verbatim wording from the response “This government is also working to improve hospital flow to make sure people do not spend longer than necessary in hospital and reduce delayed discharges. We will tackle delayed discharges by developing local partnership working between the NHS and social care and making sure people get the right support from health and social care services to return home as soon as possible.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase productivity across acute and non-acute bedded and non-bedded services.
Verbatim wording from the response “In the short-term, a range of action is being taken by the NHS this year to improve urgent and emergency care performance, including by maintaining capacity gains in acute hospital beds and ambulance hours on the road achieved in 2023-24, increasing the productivity of acute and non-acute services across bedded and non-bedded capacity, and directing patients to more appropriate services in the community where these can better meet their needs.” Source location Response from DHSC
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 Health and care systems and providers are responsible for coordinating hospital discharge efforts into social care.
Verbatim wording from the response “Turning to your concern regarding organisational responsibilities, health and care systems and providers should work together to ensure that efforts to discharge individuals from hospital into social care are joined up and make best use of available resources, in line with the duty to cooperate set out in Section 82 of the NHS Act 2006.” Source location Response from DHSC
Open published response
20 Sep 2024 Susan Dear · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 4 Unavailability of sufficient emergency ambulances to meet demand View source Public misunderstanding of when to call 999 causing emergency ambulance resources to be wasted View source Chronic understaffing of emergency ambulance response services View source Delays in hospital handover of ambulance patients 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
Susan Dear · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Susan Dear developed abdominal pain and, after a prolonged wait for an ambulance, was driven to hospital by her family, where she was recognised as deceased shortly after arrival on 4 January 2023. The principal concerns were severe ambulance delays caused by insufficient available resources, chronic staffing and capacity pressures, hospital handover delays, and continuing risk that emergency ambulance demand would outstrip resources.
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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 Unavailability of sufficient emergency ambulances to meet demand
Wider context from the report “(1) South Central Ambulance Service (‘SCAS’)’s internal investigation established that there had been no missed opportunity to send an ambulance during the time that Susan was waiting overnight on 3 to 4 January 2023 as none was available ; and
(2) overnight between 3-4 January 2023 patient’s lives were put at risk because SCAS did not have ambulances available to meet the level of demand resulting in severe delay and ambulance response times far outside the national expected standards; and
(3) this was not unprecedented but was reflective of a picture of a chronic situation whereby there was a continuing risk that demand for emergency ambulances would outstrip resources and SCAS were unable to reassure me this was a situation that had been resolved; and
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Public misunderstanding of when to call 999 causing emergency ambulance resources to be wasted
Wider context from the report “(7) resources were being wasted due to ignorance of some of members of the public engaging with the service , and the inquest heard that it was unlikely this would improve substantially without a programme of public education regarding when it is appropriate to call 999, and when it is not .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Chronic understaffing of emergency ambulance response services
Wider context from the report “(5) SCAS’s service was operating at under the number of planned staff for that night , (despite the service taking all reasonable steps to meet requirements) due to chronic understaffing of the service with recruitment and retention issues with paramedic and other emergency response staff that the inquest heard are problems nationally; and
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 hospital handover of ambulance patients
Wider context from the report “(6) handover delays at the Royal Berkshire Hospital and the Wexham Park Hospital were found to be a substantial root cause of the problem (due to ambulance staff being delayed at hospital with patients who could not be admitted to Accident & Emergency as other patients were unable to be admitted to the wards until beds were available) and that this was a problem that required improvement at a national level with changes to the social care system to ease the discharge of patients who required care in the community from the wards back into the community; and
” 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 Develop local NHS and social-care partnership working to tackle delayed discharges.
Verbatim wording from the response “Turning to your concerns on ambulance handover delays, this government is working to improve hospital flow to make sure people do not spend longer than necessary in hospital and reduce delayed discharges. We will tackle delayed discharges by developing local partnership working between the NHS and social care – and making sure people get the right support from health and social care services to return home as soon as possible.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve hospital flow to reduce unnecessary hospital stays and delayed discharges.
Verbatim wording from the response “Turning to your concerns on ambulance handover delays, this government is working to improve hospital flow to make sure people do not spend longer than necessary in hospital and reduce delayed discharges. We will tackle delayed discharges by developing local partnership working between the NHS and social care – and making sure people get the right support from health and social care services to return home as soon as possible.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure every acute hospital has access to a care transfer hub for complex discharges.
Verbatim wording from the response “We have also ensured that every acute hospital has access to a care transfer hub. These hubs bring together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support. In the integrated care systems that face the most discharge delays, the Department is working directly with partners across health and social care to drive improvements.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work directly with health and social-care partners in systems facing the most discharge delays to drive improvements.
Verbatim wording from the response “We have also ensured that every acute hospital has access to a care transfer hub. These hubs bring together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support. In the integrated care systems that face the most discharge delays, the Department is working directly with partners across health and social care to drive improvements.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for responding on regional service improvements and actions being taken by the ambulance trust.
Verbatim wording from the response “In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. I understand NHS England are writing to you regarding regional service improvements and actions being taken by SCAS. I am also informed they will respond to your concerns on appropriate public education about the circumstances in which it is appropriate to call 999.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for responding on public education about when it is appropriate to call 999.
Verbatim wording from the response “In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. I understand NHS England are writing to you regarding regional service improvements and actions being taken by SCAS. I am also informed they will respond to your concerns on appropriate public education about the circumstances in which it is appropriate to call 999.” Source location Response from DHSC
Open published response
6 Sep 2024 John Francis HOWLETT · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of robust monitoring of care-home residents' nutritional status and fluid intake View source Failure to move patients from emergency departments onto wards in a timely manner due to capacity constraints View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Francis HOWLETT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Francis Howlett had severe chronic obstructive pulmonary disease, was bedbound and required oxygen in a care home, where he became increasingly frail with poor nutrition and fluid intake. He developed an infection, was admitted to hospital, and died on 31 January 2024 after continuing to decline. Concerns included his spending 22 hours in an emergency department corridor and the care home’s inadequate systems for robustly monitoring his nutritional status and fluid intake.
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 robust monitoring of care-home residents' nutritional status and fluid intake
Wider context from the report “2. The evidence before the inquest indicated that the care home in question had been of concern in relation to the care offered to residents for some time. It was indicated that action plans were in place particularly in relation to safeguarding concerns given the vulnerability of residents. However despite those steps being in place and the concerns the systems were not in place at the care home to robustly monitor his nutritional status and fluid intake . He became increasingly frail with decreased physiological reserves as a consequence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 move patients from emergency departments onto wards in a timely manner due to capacity constraints
Wider context from the report “1. The inquest heard that on arrival at A and E at Tameside Hospital Mr Howlett spent 22 hours in a corridor despite suffering from an infection and the distress that this caused. The inquest was told that this was due to the demands on the department and the challenges of moving patients onto wards due to capacity issues . The inquest was told that this was not unique to that particular day or indeed to the hospital and was the picture across the country at that time .
” 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 No Safeguarding Adults Review was considered necessary because learning was identified for the care home, but not for wider partners.
Verbatim wording from the response “It is good practice for a local authority’s Safeguarding Adults Board (SAB) to work with coroners. You may have already contacted the local SAB about whether they have considered Safeguarding Adults Review (SAR). However separately DHSC officials reached out to Tameside SAB.” Source location Response from DHSC
Open published response
6 Sep 2024 Emilia ALLSOPP · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of suitable community-based dementia support for family carers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emilia ALLSOPP · 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
Emilia Allsopp, who had dementia and significant cardiac conditions, suffered an accidental fall at her care home. A fracture was not initially diagnosed, but was identified after she returned to hospital the following day; she later developed a lower respiratory tract infection and died at Tameside General Hospital on 15 January 2024. The principal concern was the lack of suitable community-based support, which meant her family could no longer care for her at home and she moved to an unfamiliar care-home environment.
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 suitable community-based dementia support for family carers
Wider context from the report “The inquest heard evidence that Mrs Allsopp had struggled at the care home due to it being an unfamiliar environment. Her family had wanted her to remain cared for by them in a familiar home environment. They felt that if they were properly supported, home would be a safer environment for Mrs Allsopp. However Mrs Allsopp moved to the care home due to a lack of suitable community based support meaning that her family could no longer continue to care for her in the community. The inquest was told by her family that it had proved impossible to get the level of support they needed for Mrs Allsopp in the community as her dementia progressed . This created a situation where she was unsafe in her own home and had to move to a new less familiar setting. Effective dementia support for the family would have meant that could have continued to look after her at home.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local authorities are responsible for assessing and meeting eligible carers’ support needs under the Care Act 2014.
Verbatim wording from the response “I am sorry to hear that Mrs Allsopp’s family did not receive the level of support they felt they required to continue caring for Mrs Allsopp in her home. The Care Act 2014 requires local authorities to deliver a wide range of sustainable, high-quality care and support services, including support for carers. Local Authorities have duties to support people caring for their family and friends. They are also required to undertake Carer’s Assessments to support people caring for their family and friends who appear to have a need for support and local authorities are required to meet their eligible needs on request from them. The Care Quality Commission is assessing how well local authorities are meeting their duties under Part 1 of the Care Act 2014, including those relating to carers.” Source location Response from DHSC
Open published response
Concerns raised 3 Unavailability of therapeutic crisis alternatives to secure hospital admission View source Shortage of staff View source Insufficient capacity for autism assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Brandon William Turner · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Brandon William Turner, who had diagnoses of PTSD and autism, died from suicide on 21 June 2023 at age 21; the recorded cause of death was asphyxia from fatal pressure on the neck. He had been referred to a community mental health therapy pathway, but treatment had not commenced before his death. Concerns included staffing shortages, the absence in Cornwall of a therapeutic alternative to hospital detention for people with complex PTSD/EUPD in crisis, and a lengthy autism assessment waiting list.
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 Unavailability of therapeutic crisis alternatives to secure hospital admission
Wider context from the report “(2) As noted above, the inquest was informed that where patients with complex PTSD/EUPD present in crisis, national and local practice is not to detain in a secure hospital. The inquest also heard that in other areas of the country there is a therapeutic alternative of admission to a day hospital (ie not detained, but somewhere to permit de-escalation) or to a crisis unit/house/café. That option is not currently available in Cornwall.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Shortage of staff
Wider context from the report “(1) Shortage of staff. This has been a longstanding concern in Cornwall. I am aware there have been initiatives undertaken nationally and internationally and yet the problem remains. It seems this is not an issue that can be resolved by the local ICB and so this concern is directed to the Secretary of State for her attention and formal response.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 capacity for autism assessments
Wider context from the report “(3) The inquest heard that CPFT is commissioned to assess 140 patients annually for autism. The current waiting list for assessment is in the region of two years. In other words, the demand for the service greatly exceeds the current supply.
” Open source report
30 Aug 2024 Terence Harry Clark · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Patient safety investigations failing to review evidence relevant to governance and coronial investigations View source Failure to secure and document clinical apparatus relevant to investigations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Terence Harry Clark · 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
Terence Harry Clark, who had an impaired swallow and aspiration pneumonia, was admitted to hospital on 26 October 2023 and died there on 1 November 2023 after sustaining a cardiac arrest while waiting unescorted in an X-ray waiting area. Concerns included the discovery of liquid food in his airway, the unexplained removal and loss of his naso-gastric tube, and the failure to identify the tube’s removal as a significant factor during the patient safety investigation, which impeded investigation of the death.
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 Patient safety investigations failing to review evidence relevant to governance and coronial investigations
Wider context from the report “B. The Trust conducted a patient safety investigation into the circumstances leading to Mr Clark’s death, the investigation did not identify the removal of the NG tube as a significant factor worthy of scrutiny. Both of these issues raise a concern that the Trust can not adequately secure and review evidence relevant to governance and coronial investigations , necessary to mitigate risks of future fatalities.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 secure and document clinical apparatus relevant to investigations
Wider context from the report “A. Despite Mr Clark having been subject to a nil-by-mouth order for 24 hrs prior to collapse, cream-coloured liquid food was found in Mr Clark’s airway at autopsy. The NG tube, inserted on the day of death had been removed and misplaced prior to autopsy. No evidence exists to indicate, when the apparatus was removed, by whom, on whose instruction or why. The removal and loss of this apparatus impeded the proper investigation of this death.
” Open source report
27 Aug 2024 Dave Yola Onawelo · Prevention of Future Deaths report East London
View report summary
Concerns raised 5 Failure to identify critically ill patients with high-risk pre-existing comorbidities View source Lack of compassion in emergency department care View source Patient congestion in emergency departments View source Lack of clinical curiosity in emergency department assessment View source Over-reliance on the NEWS algorithm in clinical assessment 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
Dave Yola Onawelo · 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
Dave Yola Onawelo, who had sickle cell anaemia, became unwell on 30 December 2023 and was later transferred to hospital after developing difficulty breathing. While waiting in the emergency department, he deteriorated, suffered seizures and a cardiac arrest, and resuscitation was discontinued at 19.48. The principal concerns were that he was not adequately identified as critically ill and that earlier fluid resuscitation, blood transfusion and intravenous antibiotics may have resulted in a non-fatal outcome; patient congestion, over-reliance on the NEWS algorithm, and a lack of compassion and clinical curiosity were also identified as contributing factors.
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 critically ill patients with high-risk pre-existing comorbidities
Wider context from the report “A. The Trust failed to adequately identify a critically ill patient with a pre-existing co-morbidity, sickle cell anaemia, that carried with it a high risk of acute deterioration . Earlier introduction of fluid resuscitation, blood transfusion and i/v antibiotics is likely to have resulted in a non-fatal outcome. Factors in the emergency department including, patient congestion, over-reliance on the NEWS algorithm and a lack of compassion and clinical curiosity contributed to the outcome.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 compassion in emergency department care
Wider context from the report “A. The Trust failed to adequately identify a critically ill patient with a pre-existing co-morbidity, sickle cell anaemia, that carried with it a high risk of acute deterioration. Earlier introduction of fluid resuscitation, blood transfusion and i/v antibiotics is likely to have resulted in a non-fatal outcome. Factors in the emergency department including, patient congestion, over-reliance on the NEWS algorithm and a lack of compassion and clinical curiosity contributed to the outcome.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Patient congestion in emergency departments
Wider context from the report “A. The Trust failed to adequately identify a critically ill patient with a pre-existing co-morbidity, sickle cell anaemia, that carried with it a high risk of acute deterioration. Earlier introduction of fluid resuscitation, blood transfusion and i/v antibiotics is likely to have resulted in a non-fatal outcome. Factors in the emergency department including, patient congestion , over-reliance on the NEWS algorithm and a lack of compassion and clinical curiosity contributed to the outcome.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical curiosity in emergency department assessment
Wider context from the report “A. The Trust failed to adequately identify a critically ill patient with a pre-existing co-morbidity, sickle cell anaemia, that carried with it a high risk of acute deterioration. Earlier introduction of fluid resuscitation, blood transfusion and i/v antibiotics is likely to have resulted in a non-fatal outcome. Factors in the emergency department including, patient congestion, over-reliance on the NEWS algorithm and a lack of compassion and clinical curiosity contributed to the outcome.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on the NEWS algorithm in clinical assessment
Wider context from the report “A. The Trust failed to adequately identify a critically ill patient with a pre-existing co-morbidity, sickle cell anaemia, that carried with it a high risk of acute deterioration. Earlier introduction of fluid resuscitation, blood transfusion and i/v antibiotics is likely to have resulted in a non-fatal outcome. Factors in the emergency department including, patient congestion, over-reliance on the NEWS algorithm and a lack of compassion and clinical curiosity contributed to the outcome.
” 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 Complete an independent investigation into NHS performance and its challenges.
Verbatim wording from the response “Turning to your concerns on patient congestion and the pressures on the NHS more generally. This government is committed to returning NHS services to the safe operational waiting time standards set out in the NHS Constitution. In doing so, we will be honest about the challenges facing the health service and serious about tackling them. As a first step, the Health Secretary ordered an independent investigation of NHS performance to provide an assessment of the issues and challenges it faces. This reported on 12th September 2024 and the investigation’s findings will feed into the government’s work on a 10-year plan to radically reform the NHS and build a health service that is fit for the future.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Return NHS services to safe operational waiting-time standards.
Verbatim wording from the response “Turning to your concerns on patient congestion and the pressures on the NHS more generally. This government is committed to returning NHS services to the safe operational waiting time standards set out in the NHS Constitution. In doing so, we will be honest about the challenges facing the health service and serious about tackling them. As a first step, the Health Secretary ordered an independent investigation of NHS performance to provide an assessment of the issues and challenges it faces. This reported on 12th September 2024 and the investigation’s findings will feed into the government’s work on a 10-year plan to radically reform the NHS and build a health service that is fit for the future.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local care concerns are assigned to Barts Health NHS Foundation Trust, which is responsible for responding and taking local improvement steps.
Verbatim wording from the response “The Government is clear that patients should expect and receive the highest standard of service and care from the NHS. You have raised the concerns about the care Mr Onawelo received directly with the responsible NHS body, the Barts Health NHS Foundation Trust. I understand the trust will be responding to you directly on the steps they are taking locally; this includes action to help improve the awareness and care provided in the emergency department for patients with sickle cell anaemia, and action to increase the number of nurses to help support increased patient demand in the emergency department.” Source location Response from DHSC
Open published response
23 Aug 2024 Allan Robin Hamilton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to provide effective triage of electronic patient contacts by medically qualified staff View source Failure to track and regularly check electronic patient contacts View source Lack of a clear audit trail for electronic patient contacts View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Allan Robin Hamilton · 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
Allan Robin Hamilton emailed his GP practice on 14 November 2023 about breathing difficulties, but the email was not responded to until 17 November. He was found unresponsive at home on 19 November and died from lobar pneumonia. The principal concerns were the absence of systems for tracking and triaging email queries and the lack of clear, robust audit and follow-up processes.
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 effective triage of electronic patient contacts by medically qualified staff
Wider context from the report “The inquest heard evidence that the GP practice in question is owned by SSP Health. The company owns a number of GP practices and that operate on a similar model. Like many GP practices the surgery in question had moved to a system where contact was encouraged electronically.
The surgery had no system for tracking email queries such as the one sent by Mr Hamilton and there was no clear system for triage of emails such as the one he sent .
The inquest heard evidence that an electronic system of patient referrals is only effective if there is a clear and robust process for checking regularly for patient contacts, a clear audit trial and effective triage by medically qualified members of the team .
In Mr Hamilton’s case effective scrutiny of his query and follow up contact from his GP on 14/11 and medical advice would probably have meant he would not have died when he did.
The inquest heard evidence that there was a risk of a similar situation arising if GP practices do not have clear and robust triage and audit processes in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 track and regularly check electronic patient contacts
Wider context from the report “The inquest heard evidence that the GP practice in question is owned by SSP Health. The company owns a number of GP practices and that operate on a similar model. Like many GP practices the surgery in question had moved to a system where contact was encouraged electronically.
The surgery had no system for tracking email queries such as the one sent by Mr Hamilton and there was no clear system for triage of emails such as the one he sent.
The inquest heard evidence that an electronic system of patient referrals is only effective if there is a clear and robust process for checking regularly for patient contacts , a clear audit trial and effective triage by medically qualified members of the team.
In Mr Hamilton’s case effective scrutiny of his query and follow up contact from his GP on 14/11 and medical advice would probably have meant he would not have died when he did.
The inquest heard evidence that there was a risk of a similar situation arising if GP practices do not have clear and robust triage and audit processes in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 clear audit trail for electronic patient contacts
Wider context from the report “The inquest heard evidence that the GP practice in question is owned by SSP Health. The company owns a number of GP practices and that operate on a similar model. Like many GP practices the surgery in question had moved to a system where contact was encouraged electronically.
The surgery had no system for tracking email queries such as the one sent by Mr Hamilton and there was no clear system for triage of emails such as the one he sent.
The inquest heard evidence that an electronic system of patient referrals is only effective if there is a clear and robust process for checking regularly for patient contacts, a clear audit trial and effective triage by medically qualified members of the team.
In Mr Hamilton’s case effective scrutiny of his query and follow up contact from his GP on 14/11 and medical advice would probably have meant he would not have died when he did.
The inquest heard evidence that there was a risk of a similar situation arising if GP practices do not have clear and robust triage and audit processes in place.
” 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 Individual practices are responsible for establishing reliable systems and managing email correspondence according to their local requirements.
Verbatim wording from the response “General practices are independent businesses who are contracted by NHS commissioners to perform medical services, and as a result it is the responsibility of the individual practice (provider) to have reliable systems in place to manage interactions with patients. If a” Source location Response from DHSC
Open published response
20 Aug 2024 Miss Hannah Enola Angela Ayomipo Jacobs · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Absence of an appropriate structure to educate schools, patients and parents about carrying adrenaline autoinjectors during journeys to and from school View source Lack of arrangements to contain the risk of anaphylaxis during journeys to and from school 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
Miss Hannah Enola Angela Ayomipo Jacobs · 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
Hannah Jacobs, aged 13, died on 8 February 2023 after consuming a dairy milk hot chocolate despite having severe dairy allergies and developing anaphylaxis. She and her mother were not carrying an adrenaline auto-injector, and the available paediatric injector at the pharmacy was an insufficient dosage. The report identified concerns about arrangements for carrying auto-injectors between home and school and the need to educate schools, patients and parents about carrying them.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of an appropriate structure to educate schools, patients and parents about carrying adrenaline autoinjectors during journeys to and from school
Wider context from the report “• Hannah was regularly prescribed Epi-pens (AAI) and had 2 at home and 2 at school. There was no consideration about how to contain the risk of anaphylaxis on the journey to and from school.
• Her paediatrician gave evidence at the inquest and acknowledged it was a difficult issue as the pens can be misused, lost, forgotten, leaving an absence of pens at home at the weekend. However, the largest cause of mortality in anaphylaxis is the absence of a readily available adrenaline autoinjector.
• The risk of future deaths in the context of anaphylaxis remain in the absence of an appropriate structure to educate the school, patients and the parents of the importance of carrying an AAI on their way to and from school.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 arrangements to contain the risk of anaphylaxis during journeys to and from school
Wider context from the report “• Hannah was regularly prescribed Epi-pens (AAI) and had 2 at home and 2 at school. There was no consideration about how to contain the risk of anaphylaxis on the journey to and from school.
• Her paediatrician gave evidence at the inquest and acknowledged it was a difficult issue as the pens can be misused, lost, forgotten, leaving an absence of pens at home at the weekend. However, the largest cause of mortality in anaphylaxis is the absence of a readily available adrenaline autoinjector.
• The risk of future deaths in the context of anaphylaxis remain in the absence of an appropriate structure to educate the school, patients and the parents of the importance of carrying an AAI on their way to and from school.
” Open source report
13 Aug 2024 Elizabeth Van Der Drift · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Failure of product appearance and packaging to avoid confusion with food View source Production of laundry tablets/pods and packaging that can be confused with food by people with cognitive impairment View source Lack of packaging design features that make accessing laundry tablets/pods difficult View source Lack of packaging safety features restricting access to laundry capsules View source Food-imitation regulations insufficiently protective of people with cognitive impairment or insufficiently rigorously applied 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.
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AI-generated summary
Elizabeth Van Der Drift · 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
Elizabeth Van Der Drift, who had dementia, accessed brightly coloured laundry detergent capsules on the night of 13/14 March 2024, apparently mistaking them for sweets, and bit into at least one. She was taken to hospital and died on 19 March 2024 despite treatment. The report raised concerns that the product’s colours, appearance and packaging could lead to accidental ingestion by people with dementia or other cognitive impairment, and that its packaging lacked a safety feature making access particularly difficult.
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 product appearance and packaging to avoid confusion with food
Wider context from the report “(1) The product in question, Sainsbury’s Tropical Escape Bio Laundry Capsules, due to its eye-catching colours, appearance, and packaging, is being confused with food and risks being accidently ingested by those with dementia or other cognitive impairment (as well as children) .
(2) There was no safety feature observed on the packaging that made accessing the content particularly difficult, which increases the risk of accidental or inadvertent ingestion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Production of laundry tablets/pods and packaging that can be confused with food by people with cognitive impairment
Wider context from the report “(1) During the course of hearing the evidence I was shown a picture of the packaging for the laundry tablets/pods in question. The packaging, in this instance, was predominantly bright pink and white, with orange, yellow and green also present. One witness (a carer experienced in caring for those living with dementia) gave me her view that the packaging bore more than a passing resemblance to a bag of sweets, and she considered that this was more likely to be the case when viewed from the point of view of a person living with dementia or some other cognitive impairment.
In my view, the packaging of this particular product is not alone among similar products, that also opt for bright, eye-catching colours. It was for this reason that I formed the view that sending this report to the individual manufacturer/retailer (under whose brand the product was labelled) would be short-sighted. The employment of eye-catching and bright colours appears to be an industry-wide phenomenon.
It has long been acknowledged that products of this nature can pose risks to children; however, there appears to be less acknowledgement of the risks posed to those living with dementia or other forms of cognitive impairment .
In terms of the laundry tablets/pods themselves, I note that these have a jelly-like appearance and again I regard them as being colourful and potentially sweet-like in their appearance . This again has the serious potential to render a highly toxic/hazardous product as appealing to those with dementia or other cognitive impairment (as well as children). There is a wealth of material available (media reports, scientific studies and research etc.) to document the relatively frequency that products of this nature are accidentally or inadvertently ingested.
I am well aware of The Food Imitations (Safety) Regulations 1989, UKSI 1989 No. 1291 and note Regulation 4, in particular. However, it seems to me either that the regulations themselves have insufficient regard to those living with dementia or other cognitive impairment or that the application of the regulations is not approached with sufficient rigour.
The overarching concern here is that laundry tablets/pods and their packaging are being produced in a way that, by virtue of their bright colouring, appearance, and packaging, are being confused with food by people living with dementia or other cognitive impairment . The issue is, in my opinion, compounded when one considers that the products themselves are far from innocuous in the event of their accidental ingestion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 packaging design features that make accessing laundry tablets/pods difficult
Wider context from the report “(2) In this case, I also noted that there was no obvious design feature, in terms of the packaging, that makes accessing the content particularly difficult for someone with even the most basic of manual dexterity . In my view, this only adds to the risks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of packaging safety features restricting access to laundry capsules
Wider context from the report “(1) The product in question, Sainsbury’s Tropical Escape Bio Laundry Capsules, due to its eye-catching colours, appearance, and packaging, is being confused with food and risks being accidently ingested by those with dementia or other cognitive impairment (as well as children).
(2) There was no safety feature observed on the packaging that made accessing the content particularly difficult , which increases the risk of accidental or inadvertent ingestion .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Food-imitation regulations insufficiently protective of people with cognitive impairment or insufficiently rigorously applied
Wider context from the report “(1) During the course of hearing the evidence I was shown a picture of the packaging for the laundry tablets/pods in question. The packaging, in this instance, was predominantly bright pink and white, with orange, yellow and green also present. One witness (a carer experienced in caring for those living with dementia) gave me her view that the packaging bore more than a passing resemblance to a bag of sweets, and she considered that this was more likely to be the case when viewed from the point of view of a person living with dementia or some other cognitive impairment.
In my view, the packaging of this particular product is not alone among similar products, that also opt for bright, eye-catching colours. It was for this reason that I formed the view that sending this report to the individual manufacturer/retailer (under whose brand the product was labelled) would be short-sighted. The employment of eye-catching and bright colours appears to be an industry-wide phenomenon.
It has long been acknowledged that products of this nature can pose risks to children; however, there appears to be less acknowledgement of the risks posed to those living with dementia or other forms of cognitive impairment.
In terms of the laundry tablets/pods themselves, I note that these have a jelly-like appearance and again I regard them as being colourful and potentially sweet-like in their appearance. This again has the serious potential to render a highly toxic/hazardous product as appealing to those with dementia or other cognitive impairment (as well as children). There is a wealth of material available (media reports, scientific studies and research etc.) to document the relatively frequency that products of this nature are accidentally or inadvertently ingested.
I am well aware of The Food Imitations (Safety) Regulations 1989, UKSI 1989 No. 1291 and note Regulation 4, in particular. However, it seems to me either that the regulations themselves have insufficient regard to those living with dementia or other cognitive impairment or that the application of the regulations is not approached with sufficient rigour .
The overarching concern here is that laundry tablets/pods and their packaging are being produced in a way that, by virtue of their bright colouring, appearance, and packaging, are being confused with food by people living with dementia or other cognitive impairment. The issue is, in my opinion, compounded when one considers that the products themselves are far from innocuous in the event of their accidental ingestion.
” Open source report
8 Aug 2024 Emma Pattison and 2 others · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Failure to ensure full and accurate disclosure of shotgun certificate applicants’ history of coercive controlling behaviour View source Failure to ensure full disclosure of shotgun certificate applicants’ medical history View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emma Pattison and 2 others · 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
Between 22:49 on 4 February 2023 and 00:40 on 5 February 2023, George Pattison shot and killed his wife, Emma Pattison, and daughter, Ellette Pattison, before shooting himself. The report raises concerns about online medical consultations potentially bypassing disclosure safeguards for shotgun licensing and about obtaining full information concerning coercive controlling behaviour.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure full and accurate disclosure of shotgun certificate applicants’ history of coercive controlling behaviour
Wider context from the report “3. Consideration should be given as to how a licensing authority can obtain full and accurate disclosure of an applicant’s history of coercive controlling behaviour towards another / others .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure full disclosure of shotgun certificate applicants’ medical history
Wider context from the report “1. An applicant for a shotgun certificate is able to obtain medication from an on-line doctor without the knowledge of their GP , giving rise to a risk that a licensing authority might grant a shotgun certificate to an applicant who has a relevant previous medical history about which the authority is not aware .
2. In consulting an on-line doctor, it is possible for an applicant for a shotgun certificate to avoid the current safeguards relating to full disclosure of their previous and current medical history .
” 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 Consider whether private online prescribers should inform patients’ NHS GPs about prescribed medication.
Verbatim wording from the response “In response to the issue you raise that an applicant for a shotgun certificate is able to obtain medication from an on-line doctor without the knowledge of their GP, there is no legal requirement for a GP to be informed about medication from a private online prescriber. This is an issue which the Government is considering. Third party (non-NHS) doctors or prescribers cannot share confidential patient information with a person’s NHS GP if that person objects unless they believe there is an overriding public interest justifying consent for doing so (e.g. to protect a third party from serious harm). Third party prescribers are also reliant on the patient fully disclosing all medical conditions and existing medication to be able to prescribe safely.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain a firearms-certificate digital marker in GP IT systems so relevant medical conditions can be flagged for police review.
Verbatim wording from the response “We have worked closely with the Home Office and the British Medical Association to ensure there are strong controls in place in relation to an applicant’s medical suitability which is one” Source location Response from DHSC
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 Confidentiality and data protection law restrict third-party prescribers from sharing patient information with NHS GPs without consent, absent overriding public interest.
Verbatim wording from the response “In response to the issue you raise that an applicant for a shotgun certificate is able to obtain medication from an on-line doctor without the knowledge of their GP, there is no legal requirement for a GP to be informed about medication from a private online prescriber. This is an issue which the Government is considering. Third party (non-NHS) doctors or prescribers cannot share confidential patient information with a person’s NHS GP if that person objects unless they believe there is an overriding public interest justifying consent for doing so (e.g. to protect a third party from serious harm). Third party prescribers are also reliant on the patient fully disclosing all medical conditions and existing medication to be able to prescribe safely.” Source location Response from DHSC
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 Home Office is considering concerns about firearms licensing and will respond to the report.
Verbatim wording from the response “In your report you raise the issue of whether an applicant can avoid full disclosure of their previous and current medical history. If an applicant seeks treatment from a range of healthcare providers, this is possible. The Home Office is considering the concerns you have raised in relation to the firearms licensing process and will be responding to your report in due course.” Source location Response from DHSC
Open published response
8 Aug 2024 Mrs Gillian Patricia Stokes · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Lack of clinical guidance for recognising possible radiation-induced sarcoma View source Failure to clearly communicate required follow-up to families View source Lack of protocols for first-line investigation of patients with breast implants after radiotherapy View source Failure to complete scheduled two-week follow-up after aspiration View source Insufficient duration of surveillance for radiation-induced sarcoma after breast cancer 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
Mrs Gillian Patricia Stokes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Gillian Patricia Stokes died from sarcoma of the right chest wall after previously receiving radiotherapy for breast cancer and having breast reconstructive surgery with an implant. The report raises concerns about insufficient guidance for identifying radiation-induced sarcoma and imaging the chest wall in patients with implants, the five-year surveillance period after breast cancer, and the failure to arrange a recommended two-week follow-up after aspiration.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical guidance for recognising possible radiation-induced sarcoma
Wider context from the report “(1) I am concerned that there is not any or insufficient guidance available to clinicians in regard to possible radiation induced sarcoma , or first line investigations for patients with breast implants to be able to see down to the chest wall. The Radiologist, Surgeon and Nurse advised that they did not have any specific guidance in relation to possible radiation-induced sarcoma ,
████████from the Royal Marsden advised in written evidence, that radiation induced sarcomas are increasing in incidence as more primary breast cancer patients are now offered breast conserving surgery with wide local excision and radiotherapy, rather than mastectomy alone (previously there was no radiation). Therefore, in his view the increasing use of radiotherapy leads to increased number of patients developing radiation induced sarcomas. As ████████ said from the Royal Marsden, diagnosis requires the treating clinician to recognise that this is a possibility .
Furthermore, as ████████ advised in his experience the difficulties in diagnosis are that they are sometimes not recognised by primary and secondary care teams who are the first to see the patient .
In evidence the Radiologist confirmed that the Royal College of Radiologists do not have a protocol for patients who have had previous radiotherapy and implant. Furthermore, Nurse Diagnostician confirmed there was no protocol in the ABS Best Practice Diagnostic Guidelines for radiation induced sarcoma where a patient has had an implant.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly communicate required follow-up to families
Wider context from the report “(3) I have concerns regarding the system in place at Ashford Hospital for 2 week follow ups following an aspiration following an initial assessment at the One Stop Clinic. Following the aspiration Mrs Stokes received, the Nurse advised in evidence Mrs Stokes should have had a further review after two weeks, as indicated in the paperwork, but this was not followed through by the hospital and the message was not clearly communicated to the family . This would have allowed for further follow up in case the bulge had increased in size and in pain and could have potentially identified the need to investigate further.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of protocols for first-line investigation of patients with breast implants after radiotherapy
Wider context from the report “(1) I am concerned that there is not any or insufficient guidance available to clinicians in regard to possible radiation induced sarcoma, or first line investigations for patients with breast implants to be able to see down to the chest wall . The Radiologist, Surgeon and Nurse advised that they did not have any specific guidance in relation to possible radiation-induced sarcoma,
████████from the Royal Marsden advised in written evidence, that radiation induced sarcomas are increasing in incidence as more primary breast cancer patients are now offered breast conserving surgery with wide local excision and radiotherapy, rather than mastectomy alone (previously there was no radiation). Therefore, in his view the increasing use of radiotherapy leads to increased number of patients developing radiation induced sarcomas. As ████████ said from the Royal Marsden, diagnosis requires the treating clinician to recognise that this is a possibility.
Furthermore, as ████████ advised in his experience the difficulties in diagnosis are that they are sometimes not recognised by primary and secondary care teams who are the first to see the patient.
In evidence the Radiologist confirmed that the Royal College of Radiologists do not have a protocol for patients who have had previous radiotherapy and implant . Furthermore, Nurse Diagnostician confirmed there was no protocol in the ABS Best Practice Diagnostic Guidelines for radiation induced sarcoma where a patient has had an implant .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to complete scheduled two-week follow-up after aspiration
Wider context from the report “(3) I have concerns regarding the system in place at Ashford Hospital for 2 week follow ups following an aspiration following an initial assessment at the One Stop Clinic . Following the aspiration Mrs Stokes received, the Nurse advised in evidence Mrs Stokes should have had a further review after two weeks, as indicated in the paperwork, but this was not followed through by the hospital and the message was not clearly communicated to the family. This would have allowed for further follow up in case the bulge had increased in size and in pain and could have potentially identified the need to investigate further.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient duration of surveillance for radiation-induced sarcoma after breast cancer
Wider context from the report “(2) I have a concern regarding the current surveillance period of 5 years provided to patients with breast cancer considering the latency period of radiation induced sarcoma is 10 years .
” 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 Explore with MHRA and NHSE whether more can be done to raise awareness of radiation-induced angiosarcoma among patients and clinicians.
Verbatim wording from the response “I regret to hear that Mrs Stokes died of radiation induced sarcoma as a complication of life-saving historic radiotherapy treatment for previous breast cancer in 2013. I would like to acknowledge your concern about insufficient guidance available to clinicians regarding possible radiation induced sarcoma, or first line investigations for patients with breast implants to be able to see down to the chest wall. In 2021, the Medicines and Healthcare products Regulatory Agency (MHRA) published an alert about breast implant associated anaplastic large cell lymphoma which the clinical team followed the appropriate investigations to consider. While angiosarcoma following radiation is rare, I have asked my officials to explore with MHRA and NHSE if more can be done to raise awareness of this side effect with patients and clinicians.” Source location Response from DHSC
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 Insufficient evidence on early angiosarcoma diagnosis means regular screening guidance may cause more harm than benefit.
Verbatim wording from the response “Your report raises the concern that patients with breast cancer have a 5-year surveillance period, considering that the latency period of radiation induced sarcoma which affected Mrs Stokes is 10 years. It is my understanding that the rate of recurrence of breast cancer following diagnosis is greatest in the first five years after diagnosis. Current surveillance with annual mammography for 5 years is directed at identifying recurrent breast cancer, which occurs in up to 10% of women post treatment, usually within 5 years. I have been informed that angiosarcoma occurs in 0.1% of women, presenting at around 10 years and is not reliably identified on mammography.” Source location Response from DHSC
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 Ashford & St Peters NHS Trust is responsible for responding fully to the local follow-up concern.
Verbatim wording from the response “Finally, I regret to hear that Mrs Stokes was not invited for a follow up appointment following her initial assessment within two weeks as recommended by the nurse at the Ashford Hospital One Stop Clinic, and that this requirement was not communicated clearly to her family. As this appears to be a local arrangement, I am unable to comment on this point. However, I understand that Ashford & St Peters NHS Trust is also a recipient of your Report and is preparing a full response.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department cannot comment on the two-week follow-up because it was a local arrangement.
Verbatim wording from the response “Finally, I regret to hear that Mrs Stokes was not invited for a follow up appointment following her initial assessment within two weeks as recommended by the nurse at the Ashford Hospital One Stop Clinic, and that this requirement was not communicated clearly to her family. As this appears to be a local arrangement, I am unable to comment on this point. However, I understand that Ashford & St Peters NHS Trust is also a recipient of your Report and is preparing a full response.” Source location Response from DHSC
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations