19 Jan 2024 DAVID CHARLES MITCHENER · Prevention of Future Deaths report Surrey
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Concerns raised 3 Potentially very serious risks and side effects from excessive vitamin supplement intake View source Absence of appropriate dosage warnings and guidance for vitamin supplements View source Food labelling requirements failing to require warnings about risks and side effects on packaging 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
DAVID CHARLES MITCHENER · 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
David Mitchener was admitted to East Surrey Hospital with hypercalcaemia on 10 May 2023 and died there on 20 May 2023. The substantive concerns were the potentially serious risks of excessive vitamin supplement use, the absence of appropriate dosage guidance and warnings, and food labelling requirements that did not require these risks to be stated on the packaging.
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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 Potentially very serious risks and side effects from excessive vitamin supplement intake
Wider context from the report “(1) Vitamin supplements can have potentially very serious risks and side effects when taken in excess
(2) Current food labelling requirements do not require these risks and side effects to be written on the packaging.
(3) Absence of appropriate warnings and guidance about dosage
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 appropriate dosage warnings and guidance for vitamin supplements
Wider context from the report “(1) Vitamin supplements can have potentially very serious risks and side effects when taken in excess
(2) Current food labelling requirements do not require these risks and side effects to be written on the packaging.
(3) Absence of appropriate warnings and guidance about dosage
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 labelling requirements failing to require warnings about risks and side effects on packaging
Wider context from the report “(1) Vitamin supplements can have potentially very serious risks and side effects when taken in excess
(2) Current food labelling requirements do not require these risks and side effects to be written on the packaging.
(3) Absence of appropriate warnings and guidance about dosage
” Open source report
15 Jan 2024 Dennis John William KING · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 5 Inadequacy of the action plan for addressing ambulance response concerns View source Failure of ambulance transfer triage to prioritise urgent clinician-requested transfers View source Lack of clarity in the categorisation process for urgent inter-hospital transfers View source Inadequate means for delivering centralised exigent care through regional centres View source Unavailability of ambulances for timely urgent transfers and emergency call attendances View source See 2 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
Dennis John William KING · 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 John William KING suffered a myocardial infarction after experiencing chest pain on 9 December 2022 and died on 13 December 2022 following recognised complications of emergency treatment. The report raised concerns about delays in ambulance responses and inter-hospital transfers, confusion over transfer categorisation, and the adequacy of arrangements for urgent care at regional specialist centres.
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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 Inadequacy of the action plan for addressing ambulance response concerns
Wider context from the report “a. Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.
b. Confusion as between ambulance and hospital staff and a lack of clarity in the purpose of and process for the categorisation of transfers (particularly in urgent situations) between NHS hospitals.
c. The suitability of the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver such an approach are inadequate.
d. Adequacy of the action plan provided to the court in addressing the concern at (a) above and that of ambulance attendances to 999 and 111 calls; the plan is generalised, lacking detail and any means of measurement of progress.
Evidence received at Inquest identified waits for ambulance attendance of between 5-6 hours on the evening of 9th/10th December 2022. This, in circumstances where there call relating to Mr. KING had been categorised as a category 2 response. In Mr. KING’s case he was exhibiting symptoms of having suffered/was suffering a heart attack.
In Mr. KING’s case he had arrived at hospital been triaged, assessed and arrangements for urgent lifesaving care made by competent emergency clinicians in conjunction with experts from the regional cardiac unit. This included the requirement for an urgent transfer to the regional cardiac centre. A request for an emergency transfer from West Suffolk Hospital to The Royal Papworth Hospital was subject to further computer algorithm-based triage by the ambulance service. This resulted in a several hour delay to Mr. KING’s transfer, notwithstanding the protests from competent clinical staff in the Accident and Emergency Department at West Suffolk Hospital.
The circumstances of this case raise concerns about the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver the approach are inadequate.
East of England Ambulance Service provided evidence to the Inquest, including a Report concerning its response. This plan is generalised, lacking detail and any means of measurement of progress and is inadequate in addressing the concerns raised at 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 Failure of ambulance transfer triage to prioritise urgent clinician-requested transfers
Wider context from the report “a. Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.
b. Confusion as between ambulance and hospital staff and a lack of clarity in the purpose of and process for the categorisation of transfers (particularly in urgent situations) between NHS hospitals.
c. The suitability of the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver such an approach are inadequate.
d. Adequacy of the action plan provided to the court in addressing the concern at (a) above and that of ambulance attendances to 999 and 111 calls; the plan is generalised, lacking detail and any means of measurement of progress.
Evidence received at Inquest identified waits for ambulance attendance of between 5-6 hours on the evening of 9th/10th December 2022. This, in circumstances where there call relating to Mr. KING had been categorised as a category 2 response. In Mr. KING’s case he was exhibiting symptoms of having suffered/was suffering a heart attack.
In Mr. KING’s case he had arrived at hospital been triaged, assessed and arrangements for urgent lifesaving care made by competent emergency clinicians in conjunction with experts from the regional cardiac unit. This included the requirement for an urgent transfer to the regional cardiac centre. A request for an emergency transfer from West Suffolk Hospital to The Royal Papworth Hospital was subject to further computer algorithm-based triage by the ambulance service. This resulted in a several hour delay to Mr. KING’s transfer, notwithstanding the protests from competent clinical staff in the Accident and Emergency Department at West Suffolk Hospital.
The circumstances of this case raise concerns about the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver the approach are inadequate.
East of England Ambulance Service provided evidence to the Inquest, including a Report concerning its response. This plan is generalised, lacking detail and any means of measurement of progress and is inadequate in addressing the concerns raised at 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 Lack of clarity in the categorisation process for urgent inter-hospital transfers
Wider context from the report “a. Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.
b. Confusion as between ambulance and hospital staff and a lack of clarity in the purpose of and process for the categorisation of transfers (particularly in urgent situations) between NHS hospitals.
c. The suitability of the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver such an approach are inadequate.
d. Adequacy of the action plan provided to the court in addressing the concern at (a) above and that of ambulance attendances to 999 and 111 calls; the plan is generalised, lacking detail and any means of measurement of progress.
Evidence received at Inquest identified waits for ambulance attendance of between 5-6 hours on the evening of 9th/10th December 2022. This, in circumstances where there call relating to Mr. KING had been categorised as a category 2 response. In Mr. KING’s case he was exhibiting symptoms of having suffered/was suffering a heart attack.
In Mr. KING’s case he had arrived at hospital been triaged, assessed and arrangements for urgent lifesaving care made by competent emergency clinicians in conjunction with experts from the regional cardiac unit. This included the requirement for an urgent transfer to the regional cardiac centre. A request for an emergency transfer from West Suffolk Hospital to The Royal Papworth Hospital was subject to further computer algorithm-based triage by the ambulance service. This resulted in a several hour delay to Mr. KING’s transfer, notwithstanding the protests from competent clinical staff in the Accident and Emergency Department at West Suffolk Hospital.
The circumstances of this case raise concerns about the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver the approach are inadequate.
East of England Ambulance Service provided evidence to the Inquest, including a Report concerning its response. This plan is generalised, lacking detail and any means of measurement of progress and is inadequate in addressing the concerns raised at 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 Inadequate means for delivering centralised exigent care through regional centres
Wider context from the report “a. Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.
b. Confusion as between ambulance and hospital staff and a lack of clarity in the purpose of and process for the categorisation of transfers (particularly in urgent situations) between NHS hospitals.
c. The suitability of the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver such an approach are inadequate.
d. Adequacy of the action plan provided to the court in addressing the concern at (a) above and that of ambulance attendances to 999 and 111 calls; the plan is generalised, lacking detail and any means of measurement of progress.
Evidence received at Inquest identified waits for ambulance attendance of between 5-6 hours on the evening of 9th/10th December 2022. This, in circumstances where there call relating to Mr. KING had been categorised as a category 2 response. In Mr. KING’s case he was exhibiting symptoms of having suffered/was suffering a heart attack.
In Mr. KING’s case he had arrived at hospital been triaged, assessed and arrangements for urgent lifesaving care made by competent emergency clinicians in conjunction with experts from the regional cardiac unit. This included the requirement for an urgent transfer to the regional cardiac centre. A request for an emergency transfer from West Suffolk Hospital to The Royal Papworth Hospital was subject to further computer algorithm-based triage by the ambulance service. This resulted in a several hour delay to Mr. KING’s transfer, notwithstanding the protests from competent clinical staff in the Accident and Emergency Department at West Suffolk Hospital.
The circumstances of this case raise concerns about the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver the approach are inadequate.
East of England Ambulance Service provided evidence to the Inquest, including a Report concerning its response. This plan is generalised, lacking detail and any means of measurement of progress and is inadequate in addressing the concerns raised at 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 Unavailability of ambulances for timely urgent transfers and emergency call attendances
Wider context from the report “a. Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.
b. Confusion as between ambulance and hospital staff and a lack of clarity in the purpose of and process for the categorisation of transfers (particularly in urgent situations) between NHS hospitals.
c. The suitability of the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver such an approach are inadequate.
d. Adequacy of the action plan provided to the court in addressing the concern at (a) above and that of ambulance attendances to 999 and 111 calls; the plan is generalised, lacking detail and any means of measurement of progress.
Evidence received at Inquest identified waits for ambulance attendance of between 5-6 hours on the evening of 9th/10th December 2022. This, in circumstances where there call relating to Mr. KING had been categorised as a category 2 response. In Mr. KING’s case he was exhibiting symptoms of having suffered/was suffering a heart attack.
In Mr. KING’s case he had arrived at hospital been triaged, assessed and arrangements for urgent lifesaving care made by competent emergency clinicians in conjunction with experts from the regional cardiac unit. This included the requirement for an urgent transfer to the regional cardiac centre. A request for an emergency transfer from West Suffolk Hospital to The Royal Papworth Hospital was subject to further computer algorithm-based triage by the ambulance service. This resulted in a several hour delay to Mr. KING’s transfer, notwithstanding the protests from competent clinical staff in the Accident and Emergency Department at West Suffolk Hospital.
The circumstances of this case raise concerns about the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver the approach are inadequate.
East of England Ambulance Service provided evidence to the Inquest, including a Report concerning its response. This plan is generalised, lacking detail and any means of measurement of progress and is inadequate in addressing the concerns raised at the Inquest.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £200 million of additional ambulance funding to expand capacity and improve response times.
Verbatim wording from the response “Your report highlights that EEAST were under high demand at the time of the incident. A primary aim of the delivery plan is to boost ambulance capacity. Ambulance services are receiving £200 million of additional funding this year to expand capacity and improve response times alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” 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 Boost the number of paramedics by up to 15,600 through the NHS Long Term Workforce Plan.
Verbatim wording from the response “Regarding staffing capacity, we have made significant investments in the ambulance workforce – the number of NHS ambulance staff and support staff has increased by over 50% since 2010. To help ensure we have the ambulance workforce to meet the future demands on the service, the NHS Long Term Workforce Plan sets out plans to boost the number of paramedics by up to 15,600 to deliver services in ambulance and other care settings.” 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 Increase the NHS ambulance and support workforce.
Verbatim wording from the response “Regarding staffing capacity, we have made significant investments in the ambulance workforce – the number of NHS ambulance staff and support staff has increased by over 50% since 2010. To help ensure we have the ambulance workforce to meet the future demands on the service, the NHS Long Term Workforce Plan sets out plans to boost the number of paramedics by up to 15,600 to deliver services in ambulance and other care settings.” 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 Publish the Delivery Plan for Recovering Urgent and Emergency Care Services.
Verbatim wording from the response “I recognise the pressures our A&E and ambulance services are facing and the impact of waiting times for patients. That is why we published our ambitious Delivery Plan for Recovering Urgent and Emergency Care Services which aims to deliver sustained improvements in waiting times. The ambition is for 76% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2024, and to reduce Category 2 ambulance response times to 30 minutes on average this year.” 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 Provide £1.6 billion over two years to support timely and effective hospital discharge.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving hospital’s patient flow and bed capacity. We have met our planned targets of delivering 5,000 more staffed, permanent hospital beds, supported by £1 billion of dedicated funding, and increased virtual ward bed capacity to over 10,000 ahead of winter. This builds on the £500 million used last winter and a further £1.6” 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 Deliver new ambulances and specialist mental health vehicles.
Verbatim wording from the response “Your report highlights that EEAST were under high demand at the time of the incident. A primary aim of the delivery plan is to boost ambulance capacity. Ambulance services are receiving £200 million of additional funding this year to expand capacity and improve response times alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England and the ambulance trust are responsible for responding to the report’s specific concerns within their respective remits.
Verbatim wording from the response “Your report raised concerns about ambulance response times, delays in transferring patients to specialist units within the East of England, the centralisation of services and the action plan provided by the local ambulance trust. I understand that NHS England (NHSE) has written to you to respond to those specific concerns within their remit as have East of England Ambulance Service Trust (EEAST) on action being taken locally. NHSE note in their response note if ambulances are not available immediately for patient transfers, the incident should be escalated to ensure an appropriate response.” Source location Response from Department of Health and Social Care
Open published response
8 Jan 2024 Sarah Julie MITCHELL · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 2 Failure to limit medication dispensing in line with overdose-risk controls View source Lack of accident and emergency staff access to medication records and dispensing rationale 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
Sarah Julie MITCHELL · 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
Sarah Julie MITCHELL, who had a history of chronic back pain, medication dependence, and previous overdoses, was found deceased at her residence on 22 September 2022. The post-mortem found multiple drug toxicity from prescribed medication. The principal concerns were that she received 28 days’ worth of medication in less than 48 hours despite known overdose and hoarding risks, and that emergency department staff had no process for accessing relevant medication records and dispensing information.
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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 limit medication dispensing in line with overdose-risk controls
Wider context from the report “The provision to Ms. MITCHELL of 28 days’ worth of prescribed medication in less than a 48-hour period (14 days’ worth of medication dispensed on each occasion she was discharged hospital on the 3rd and 4th of August 2022). This occurred at a time when, due to concerns about Ms. MITCHELL hoarding medication and taking an overdose, she was receiving weekly medication prescriptions from her GP to control this risk .
The evidence heard at Inquest indicated that there was no process in place whereby accident and emergency staff could access Ms. MITCHELL’s medical records detailing the medication she was receiving and the rationale behind the dispensing regime 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 accident and emergency staff access to medication records and dispensing rationale
Wider context from the report “The provision to Ms. MITCHELL of 28 days’ worth of prescribed medication in less than a 48-hour period (14 days’ worth of medication dispensed on each occasion she was discharged hospital on the 3rd and 4th of August 2022). This occurred at a time when, due to concerns about Ms. MITCHELL hoarding medication and taking an overdose, she was receiving weekly medication prescriptions from her GP to control this risk.
The evidence heard at Inquest indicated that there was no process in place whereby accident and emergency staff could access Ms. MITCHELL’s medical records detailing the medication she was receiving and the rationale behind the dispensing regime 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 The Trust’s investigative action and prescribing policy are considered to address concerns about A&E access to medication records.
Verbatim wording from the response “In preparing this response, Departmental officials have made enquiries with NHS England. As I understand, the James Paget University Hospitals NHS Trust (the Trust) has provided a response which gives an update on the investigative action undertaken and assurance around the Trust’s prescribing policy. I trust their response addresses your specific concern around access to medical records for A&E staff.” Source location Response from Department of Health and Social Care
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 is responsible for delivering health services and considering further responses concerning access to medical records.
Verbatim wording from the response “Following this, I am aware that ████████ in his capacity as Medical Director of NHS England too has provided a response. NHS England has provisioned a programme of work to transition records from the existing system to the new National Care Records Service (NCRS) service, which I note, by design will remove a large amount of the reported barriers to adoption within many care settings. NHS England is operationally responsible for delivering health services across the country and will carefully consider further responses provided by the Trust. I hope that as an executive non-departmental public body, sponsored by the Department of Health and Social Care, the response provided by NHS England has addressed your concern.” Source location Response from Department of Health and Social Care
Open published response
4 Jan 2024 Elizabeth Roberts · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Residual staffing shortages in the District Nursing Service 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
Elizabeth Roberts · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Elizabeth Roberts was severely frail and bedbound and developed a large sacral sore with sepsis, followed by congestive cardiac failure. She died at Tameside General Hospital on 19 May 2023; the principal concern was residual staffing shortages in the District Nursing Service, which the Trust was unable to resolve without a national change of approach.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Residual staffing shortages in the District Nursing Service
Wider context from the report “(1) Despite a number of measures being undertaken by Tameside and Glossop Integrated Care and NHS Foundation Trust, the Inquest heard that there are residual staffing shortages in the District Nursing Service which the Trust is unable to resolve without a change of approach nationally.
” 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 Increase NHS nurse numbers, including community nursing capacity, to address staffing shortages.
Verbatim wording from the response “Nationally, we have taken steps to increase nurse numbers and in September 2023 we met our commitment to delivering 50,000 more nurses working in the NHS compared with September 2019.” Source location Response from Department of Health and Social Care
Open published response
3 Jan 2024 James Arthur HOLGATE · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 1 Unclear or incorrect legal interpretation preventing medical research/training establishments from accepting bodies subject to inquest 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
James Arthur HOLGATE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Arthur HOLGATE, aged 89, was admitted after recurrent falls and progressive decline, sustained a traumatic head injury after a fall in the Emergency Department, deteriorated, and died on 1 November 2023. The report raises concern that medical research and training establishments may be unable to accept body donations where an inquest is pending, potentially because of an anomaly or uncertainty in the interpretation of the Human Tissue Act 2004.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 or incorrect legal interpretation preventing medical research/training establishments from accepting bodies subject to inquest
Wider context from the report “Nottingham politely declined, they indicated that they were prevented from accepting due to what appears to be an anomaly in the law . As the matter was subject of a coronial inquest they could not accept the donation.
In non-inquest matters reported to the coroner, where post mortem examination is not required and the coroner is content there is no requirement to investigate further, a form A is signed to indicate this and the coroner is then able to return the deceased back in to the care of their family/personal representative/funeral director to allow funeral arrangements or body donation to proceed. In these instances medical research/training establishments are able to accept donation.
Where a coroner is likely to hold an inquest in a situation where a post mortem is not necessary as a cause of death statement can be obtained and the coroner is content that there is no further need to retain the deceased for any further examination, the coroner must also ensure that the deceased is returned back to the care of the family/personal representative/funeral director as soon as practicable. This normally allows for funeral arrangements to proceed.
In both instances the coroner authorises release of the deceased, in majority of cases the person is cremated ie they will not be available nor required for the coroner, even when the matter is proceeding to inquest. All relevant enquiries have to be made and sufficient evidence obtained before the release is authorised.
It is surprising therefore that the medical research/training establishments are stating that they are prevented from accepting people that are to be the subject of an inquest due to the Human Tissue Act . I fully accept there may be some circumstances where it would be inappropriate however if the coroner has no reason to object then the fact that the death is the subject of an inquest should not prevent the donation .
On reading the legislation, the establishments are either indicating an anomaly in the law or interpreting it incorrectly and guidance may be required .
Human Tissue Act 2004 covers donation. Section 11 covers permission required from a coroner, it reads:
11 Coroners
(1)Nothing in this Part applies to anything done for purposes of functions of a coroner or under the authority of a coroner.
(2)Where a person knows, or has reason to believe, that—
(a)the body of a deceased person, or
(b)relevant material which has come from the body of a deceased person,
is, or may be, required for purposes of functions of a coroner, he shall not act on authority under section 1 in relation to the body, or material, except with the consent of the coroner.
However the medical research/training establishments refer to section 1(3) of the act which explicitly states the body cannot be accepted unless the death has been registered. Section 1 Subsection (3) HTA states:
1 Authorisation of activities for scheduled purposes
1(3)The use of the body of a deceased person for the purpose of anatomical examination shall be lawful if done—
(a)with appropriate consent, and
(b)after the death of the person has been registered—
(i)under section 15 of the Births and Deaths Registration Act 1953, or
(ii)under Article 21 of the Births and Deaths Registration (Northern Ireland) Order 1976.
Matters that proceed to inquest are not registered until the close of the inquest. Some inquests are dealt with in a very timely manner, however some may take some months to conclude.
It appears that the consent in Section 11 may have the ability to override the consent required in Section 1(3), if it is then organisations are not interpreting it this way .
” 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 Discuss with the Human Tissue Authority how to clarify guidance and codes of practice on body storage and use criteria, including their interaction with section 11.
Verbatim wording from the response “The Department appreciates that the need for coroners’ consent in section 11 of the Human Tissue Act could allow room for confusion with regards to the criteria for storage and use of a deceased body for anatomical purposes under Section 1, particularly where a coroner is holding an inquest but has released the body. We propose therefore to discuss with the Human Tissue Authority how they can ensure that their guidance and codes of practice provide” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 3 Failure to ensure Cardiology team awareness and access to the emergency GP telephone number View source Failure to complete referrals needed for UHCW Multi-Disciplinary Team discussion View source Failure of Medical Consultants and staff to access the UHCW switchboard 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
Andrew Douglas Guillaume · 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
Andrew Douglas Guillaume was admitted to Warwick Hospital on 5 June 2023 with shortness of breath and a cough, and was later assessed as likely having severe aortic stenosis requiring urgent referral. He deteriorated, was admitted to the Cardiothoracic Critical Care unit at UHCW on 19 June 2023, and died on 20 June 2023; concerns included difficulties contacting the UHCW switchboard, lack of awareness of an emergency contact number, and the absence of a completed referral preventing discussion at a multi-disciplinary meeting.
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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 ensure Cardiology team awareness and access to the emergency GP telephone number
Wider context from the report “(2) A previous incident in which a similar concern had been raised, had led to provision of an emergency GP phone number, that can be used by the clinical teams at SWFT, which is manned 24 hours a day and is prioritised over other calls. The Cardiology team had not been aware of this, nor did they have the telephone number .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 referrals needed for UHCW Multi-Disciplinary Team discussion
Wider context from the report “(3) Mr Guillaume was not discussed at the Multi-Disciplinary Team meeting with UHCW on 9 June 2023 , as the referral had not been completed .
(4) Had the referral been completed, the team at UHCW could have prioritised the patient’s 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 Medical Consultants and staff to access the UHCW switchboard
Wider context from the report “(1) The inability of Medical Consultants and staff to get through to the switchboard at UHCW on two occasions .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for addressing communication about patient-transfer referrals primarily rests with the Trusts involved.
Verbatim wording from the response “The matters of concern raised are primarily for the Trusts to address, and I note both the South Warwickshire University NHS Foundation Trust (SWFT) and the University Hospitals Coventry and Warwickshire NHS Trust (UHCW) have addressed your concerns in detail in their responses. Local collaborations and working options are being explored to develop long term technological solution and short-term measures so this does not happen again. Several recommendations and actions have also been completed by the SWFT which address your concerns directly. I also note that NHS England has replied and are sighted on the issues you raised.” Source location Response from Department of Health and Social Care
Open published response
28 Dec 2023 Adrian Brendan GALLAGHER · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 3 Availability of suicide-assistance material online View source Failure to conduct age and identity checks before purchase View source Online sale of drugs for ending life View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Adrian Brendan GALLAGHER · 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
Adrian Gallagher was found deceased in bed on 10 November 2017 after being admitted to Hollins Park Hospital and receiving periods of unsupervised leave. His death was due to an intentional overdose and the inquest concluded that it was suicide. Concerns included the online availability of materials and drugs that could assist suicide, limited age and identity checks, and access by vulnerable mental health patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Availability of suicide-assistance material online
Wider context from the report “████████ is available to anyone to purchase online, directly from the company. The company appears to have some link to the UK as there is a UK helpline number. The ████████ appears to provide step by step instruction on how to end your life using certain methods, including how to make the death appear to be due to natural causes and therefore avoid referral to the coroner. Whilst the introduction suggests it is aimed at those who are elderly and long-term suffering, there is also reference to suicide for other reasons within the book and is likely to appear to vulnerable mental health patients.
According to the evidence of the police officer, you can also buy drugs to end your life through this website.
The only check on age and ID appears to be after a purchase, to allow you access to online forums where you can get further advice on best methods.
The ████████ has been banned in Australia (and possibly other countries) as it is deemed to encourage/ assist in suicide.
The ████████, in some format, is also available on Amazon (and I am writing to Amazon directly to flag this).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 age and identity checks before purchase
Wider context from the report “████████ is available to anyone to purchase online, directly from the company. The company appears to have some link to the UK as there is a UK helpline number. The ████████ appears to provide step by step instruction on how to end your life using certain methods, including how to make the death appear to be due to natural causes and therefore avoid referral to the coroner. Whilst the introduction suggests it is aimed at those who are elderly and long-term suffering, there is also reference to suicide for other reasons within the book and is likely to appear to vulnerable mental health patients.
According to the evidence of the police officer, you can also buy drugs to end your life through this website.
The only check on age and ID appears to be after a purchase , to allow you access to online forums where you can get further advice on best methods .
The ████████ has been banned in Australia (and possibly other countries) as it is deemed to encourage/ assist in suicide.
The ████████, in some format, is also available on Amazon (and I am writing to Amazon directly to flag this).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Online sale of drugs for ending life
Wider context from the report “████████ is available to anyone to purchase online, directly from the company. The company appears to have some link to the UK as there is a UK helpline number. The ████████ appears to provide step by step instruction on how to end your life using certain methods, including how to make the death appear to be due to natural causes and therefore avoid referral to the coroner. Whilst the introduction suggests it is aimed at those who are elderly and long-term suffering, there is also reference to suicide for other reasons within the book and is likely to appear to vulnerable mental health patients.
According to the evidence of the police officer, you can also buy drugs to end your life through this website.
The only check on age and ID appears to be after a purchase, to allow you access to online forums where you can get further advice on best methods.
The ████████ has been banned in Australia (and possibly other countries) as it is deemed to encourage/ assist in suicide.
The ████████, in some format, is also available on Amazon (and I am writing to Amazon directly to flag this).
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work closely with DSIT and Ofcom to support work addressing illegal and harmful online suicide and self-harm content.
Verbatim wording from the response “The Department for Science, Innovation and Technology (DSIT) will respond outlining how the Online Safety Act will address illegal and harmful self-harm and suicide content. The Department of Health and Social Care will continue to work closely with DSIT and Ofcom to support this work. We will also continue our support of programmes such as the Samaritans’ Online Excellence Programme, which provides support and guidance for some of the biggest online platforms.” Source location Response from Department of Health and Social Care
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 Lead a cross-sector, cross-government working group that meets regularly to address emerging suicide methods and remain vigilant to new intelligence.
Verbatim wording from the response “The Department of Health and Social Care leads a cross-sector, cross-government working group to tackle emerging methods, working with those partners. As a result of this group, there are now very active actions in place to reduce awareness and limit access to methods of suicide, including the one used by Mr Gallagher. The group meets regularly and remains vigilant to any further methods that we receive intelligence on, and will not hesitate to act should it be required.” Source location Response from Department of Health and Social Care
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 Seek to tackle suppliers of harmful substances intended for suicide at source.
Verbatim wording from the response “The Government is taking a leading role in tackling methods of suicide, collaborating with partners across the world in policy, law enforcement and society more broadly to limit access, and share research, evidence and lessons learned. This includes seeking to tackle at source the suppliers of harmful substances for the purposes of suicide.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate measures to reduce awareness of and limit access to suicide methods, including the method involved in the death.
Verbatim wording from the response “The Department of Health and Social Care leads a cross-sector, cross-government working group to tackle emerging methods, working with those partners. As a result of this group, there are now very active actions in place to reduce awareness and limit access to methods of suicide, including the one used by Mr Gallagher. The group meets regularly and remains vigilant to any further methods that we receive intelligence on, and will not hesitate to act should it be required.” Source location Response from Department of Health and Social Care
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 Revisit discussions with online marketplaces about selling harmful publications, working with police and suicide prevention charities.
Verbatim wording from the response “I welcome your decision to write to Amazon to flag these concerns. My officials continue to work with the police and suicide prevention charities to revisit the conversations they have had with online marketplaces on the sale of harmful publications. I would be interested to see a copy of Amazon’s response to you should they reply, to support those conversations.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review measures to reduce harm from harmful suicide and self-harm publications, monitor their impact, and learn from relevant international examples.
Verbatim wording from the response “We keep under constant review what the most appropriate actions are to take to reduce the harm caused by publications like the ████████. In doing this, we work closely with other government departments, charities and experts to review actions regularly and continue to monitor the impact. This includes learning lessons from international examples where these are relevant.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation DSIT is responsible for explaining how the Online Safety Act will address illegal and harmful suicide and self-harm content.
Verbatim wording from the response “The Department for Science, Innovation and Technology (DSIT) will respond outlining how the Online Safety Act will address illegal and harmful self-harm and suicide content. The Department of Health and Social Care will continue to work closely with DSIT and Ofcom to support this work. We will also continue our support of programmes such as the Samaritans’ Online Excellence Programme, which provides support and guidance for some of the biggest online platforms.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 4 Insufficient Emergency Medical Dispatcher staffing to meet forecasted demand View source Delays in ambulance response times View source Delays in offloading ambulance patients at hospitals View source YAS staffing below the level required to meet expected demand View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Shaun PARKS · 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
Shaun PARKS attended Doncaster Royal Infirmary with a heart attack and waited for an ambulance transfer to the Northern General Hospital. He deteriorated and died during a procedure on 13 December 2022. Concerns included a 3-hour 18-minute ambulance response delay, insufficient emergency dispatch staffing, and hospital delays in offloading patients that reduced ambulance availability.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient Emergency Medical Dispatcher staffing to meet forecasted demand
Wider context from the report “(2) There were insufficient Emergency Medical Dispatcher's available to meet the forecasted demand . Staffing at YAS was below the requirement to meet the expected demand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 ambulance response times
Wider context from the report “(1) The ambulance response time of 3 hours and 18 minutes has likely affected 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 Delays in offloading ambulance patients at hospitals
Wider context from the report “(3) There was a significant delay in offloading patients at hospitals , which tied up resources and meant they were unable to respond to emergency calls.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation YAS staffing below the level required to meet expected demand
Wider context from the report “(2) There were insufficient Emergency Medical Dispatcher's available to meet the forecasted demand. Staffing at YAS was below the requirement to meet the expected demand .
” Open source report
20 Dec 2023 James CAMPION · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 3 Insufficient ambulance service capacity during periods of high demand View source Delays in ambulance dispatch View source Delays in triaging emergency calls involving threats of overdose View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James CAMPION · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Campion, aged 57, died after consuming mirtazapine and alcohol following contact with the Psychiatric Crisis Team about taking an overdose. An ambulance was not allocated until six hours after the initial call, and he was found deceased at home when the crew arrived. The principal concerns were delays in mental health assessment, call triage and ambulance dispatch, alongside inadequate family contact information and limited family involvement.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient ambulance service capacity during periods of high demand
Wider context from the report “The delay in triaging the call made by Mr Campion threatening to take an overdose resulted in him taking the overdose. The delay in the ambulance dispatch prevented Mr Campion receiving medical treatment and further psychiatric assistance. The outcome for Mr Campion has been adversely impacted due to the demand on the ambulance service . At the time of the 999 call on 21st July 2022 NWAS were operating at Level 4 of the Plan (PSP) experiencing high demand, acute pressures and high numbers of waiting calls. The options for the emergency services were extremely limited and an ambulance was deployed at the earliest opportunity. Consideration be given to how to support the Ambulance and Mental Health Services in fulfilling the NHS long-term plan for Mental Health, in particular Mental Health Practitioners in Ambulance control rooms.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 ambulance dispatch
Wider context from the report “The delay in triaging the call made by Mr Campion threatening to take an overdose resulted in him taking the overdose. The delay in the ambulance dispatch prevented Mr Campion receiving medical treatment and further psychiatric assistance. The outcome for Mr Campion has been adversely impacted due to the demand on the ambulance service . At the time of the 999 call on 21st July 2022 NWAS were operating at Level 4 of the Plan (PSP) experiencing high demand, acute pressures and high numbers of waiting calls. The options for the emergency services were extremely limited and an ambulance was deployed at the earliest opportunity. Consideration be given to how to support the Ambulance and Mental Health Services in fulfilling the NHS long-term plan for Mental Health, in particular Mental Health Practitioners in Ambulance control rooms.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 triaging emergency calls involving threats of overdose
Wider context from the report “The delay in triaging the call made by Mr Campion threatening to take an overdose resulted in him taking the overdose. The delay in the ambulance dispatch prevented Mr Campion receiving medical treatment and further psychiatric assistance. The outcome for Mr Campion has been adversely impacted due to the demand on the ambulance service . At the time of the 999 call on 21st July 2022 NWAS were operating at Level 4 of the Plan (PSP) experiencing high demand, acute pressures and high numbers of waiting calls. The options for the emergency services were extremely limited and an ambulance was deployed at the earliest opportunity. Consideration be given to how to support the Ambulance and Mental Health Services in fulfilling the NHS long-term plan for Mental Health, in particular Mental Health Practitioners in Ambulance control rooms.
” 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 Deliver new ambulances and specialist mental health vehicles.
Verbatim wording from the response “Your report highlights that North West Ambulance Service (NWAS) was under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” Source location Response from Department of Health and Social Care
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 Publish a delivery plan to recover urgent and emergency care services and improve waiting times.
Verbatim wording from the response “The Department recognises the significant pressure the urgent and emergency care system is facing. That is why we published our Delivery plan for recovering urgent and emergency care services, which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average across this fiscal year. The plan is available at: www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf” Source location Response from Department of Health and Social Care
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 the ambulance workforce and plan to add up to 15,600 paramedics through the NHS Long Term Workforce Plan.
Verbatim wording from the response “We have also made significant investments in the ambulance workforce – the number of NHS ambulance staff and support staff has increased by over 50% since 2010. To help ensure we have the ambulance workforce to meet the future demands on the service, the NHS Long Term Workforce Plan sets out plans to boost the number of paramedics by up to 15,600 to deliver services in ambulance and other care settings.” Source location Response from Department of Health and Social Care
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 Deploy mental health professionals in 999 call centres and clinical assessment services to direct people in crisis to appropriate care.
Verbatim wording from the response “To supplement this new NHS111 offer, we are also deploying mental health professionals in 999 call centres and clinical assessment services to help ensure that people experiencing a mental health crisis are directed towards appropriate services.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain additional ambulance capacity funded to expand availability and improve response times.
Verbatim wording from the response “Your report highlights that North West Ambulance Service (NWAS) was under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 1 Failure to ensure access to histological analysis for privately funded procedures without a separate cost barrier View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gregor Patrick Edward Lynn · 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
Gregor Patrick Edward Lynn developed a neck lesion in March 2019, which was excised privately without histological analysis because of the additional cost. When the lesion recurred in May 2020, it was diagnosed as melanoma that had metastasised, and he died on 8 July 2022 after the disease spread to his brain. The principal concern was that patients paying privately for procedures may decline histological analysis because it is an additional cost, unlike within NHS treatment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure access to histological analysis for privately funded procedures without a separate cost barrier
Wider context from the report “• I was not able to conclude that, had the sample been sent for analysis in March 2019, any sign of melanoma would have been detected. Nevertheless, it is of concern that the barrier to undergoing a complete procedure, including histological analysis, appears to be one of cost . Anecdotal evidence received at inquest from treating clinicians was that the further costs associated with histological or other review, which on the NHS would be routinely included within the procedure at no charge to the patient, was a common disincentive to patients who would regularly opt not to have the further tests carried out .
• While it is acknowledged that there have to be criteria for routine and non-emergency procedures to be conducted on the NHS, my concern relates to the disparity in what is included within the treatment when undertaken privately (where histological analysis is a separate and additional cost) and what is routinely included as part of NHS treatment.
• It therefore seems to me that there is a risk of future deaths if patients not meeting the NHS referral criteria, who have to pay for procedures to be carried out privately, opt on cost grounds not to have the histological analysis which would otherwise be provided on the NHS at no charge , as it is well-established fact that earlier detection and treatment is crucial in minimising the risks of developing metastatic cancers including melanoma.
” 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 Independent sector providers determine services and fees for self-funding patients when services are outside NHS contracts.
Verbatim wording from the response “With regard to your concern about charging for additional activities by independent sector providers, it is reasonable that they should be able to charge for services which are not provided under contracts with the NHS. Ultimately, it is for independent sector” Source location Response from Department of Health and Social Care
Open published response
19 Dec 2023 Chloe Elizabeth MACDERMOTT · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 6 Lack of prominent signposting to organisations providing suicide-prevention help View source Internet availability and delivery of an unspecified item to individual users in the UK View source Open chatrooms permitting the exchange of information and methods that encourage, assist, counsel or procure suicide View source Failure of effective border and customs controls for delivery of an unspecified item to UK users View source Lack of age or other access restrictions for children, vulnerable teenagers and vulnerable adults View source Failure to effectively remove posts containing details of suicide methods 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
Chloe Elizabeth MACDERMOTT · 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
Chloe Elizabeth MACDERMOTT died at home in the early hours of 23 May 2021 after ingesting a substance purchased through Amazon US. The report identifies concerns about online forums encouraging, assisting and counselling suicide, inadequate age restrictions and signposting to help, harmful content not being effectively removed, and the availability and delivery of the product to UK users without effective border or customs controls.
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 prominent signposting to organisations providing suicide-prevention help
Wider context from the report “(6) No prominent signposting is in place to organisations from whom help is available to prevent suicide .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Internet availability and delivery of an unspecified item to individual users in the UK
Wider context from the report “(9) The availability of ████████ through the internet and its delivery to individual users in the UK with a non-commercial or agricultural use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Open chatrooms permitting the exchange of information and methods that encourage, assist, counsel or procure suicide
Wider context from the report “(3) ████████ is a forum that permits material to be exchanged and reviewed within its open chatrooms whereby suicide is encouraged, assisted, counselled and procured through the provision and exchange of information and methods .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 effective border and customs controls for delivery of an unspecified item to UK users
Wider context from the report “(10) The ability for UK users to purchase ████████ through Amazon in the United States and to take delivery in the United Kingdom without effective border and/or custom controls .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 age or other access restrictions for children, vulnerable teenagers and vulnerable adults
Wider context from the report “(5) No age or other restrictions are in place to prevent access to children, vulnerable teenagers and vulnerable adults .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively remove posts containing details of suicide methods
Wider context from the report “(7) Posts are made by users containing details of methods of suicide without any effective administration to remove such harmful content .
” 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 Lead a cross-government and cross-sector group to identify and proactively tackle emerging suicide methods, prioritising sodium nitrite.
Verbatim wording from the response “The Department leads a cross-government and cross-sector group established specifically to identify and proactively tackle emerging methods of suicide. This involves close working across government and with others to ensure we are taking rapid, targeted action to address these methods, and has been prioritising tackling sodium nitrite. Through this group’s close working, there are currently over 30 live actions and interventions that collectively are:” Source location Response from Department of Health and Social Care
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 Collaborate with international and domestic partners to limit access to suicide methods, share evidence, and tackle suppliers of harmful substances.
Verbatim wording from the response “I would like to assure you that the Government remains concerned about the prevalence of suicide and self-harm content online. The Government is taking a leading role in tackling methods of suicide, collaborating with partners across the world in policy, law enforcement and society more broadly to limit access, and share research, evidence and lessons learned. There are multiple actions in place to reduce and restrict access to this website, and others like it. This will include seeking to tackle at source the suppliers of harmful substances for the purposes of suicide.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Border Agency leads on preventing drug imports at UK borders; the NCA may provide further information on related law enforcement.
Verbatim wording from the response “I note that the Home Office is a recipient of this report and for your concerns around border and/or custom controls, I refer you to the Border Agency as the lead on preventing the importation of drugs at UK borders. A priority of the Government’s 10-year drug strategy is to “break drug supply chains.” The Government made further commitments in its Serious and Organised Crime Strategy 2023-2028, including to deliver an “end-to-end plan to tackle drugs supply”, which includes strengthening border controls on illicit commodities. The National Crime Agency (NCA), which leads and coordinates the UK law enforcement response to serious and organised crime and may also be able to provide further information on this topic.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Detailed information on how the Online Safety Act addresses illegal and harmful suicide content should be obtained from DSIT.
Verbatim wording from the response “To address your concerns about unfettered access to harmful content and restricting such content, we have made enquiries with the Department for Science, Innovation and Technology (DSIT). Under the Online Safety Act 2023 (OSA) all in-scope services such as user-to-user platforms and Search services will have new duties to prevent users being harmed by illegal content that they encounter via their services. User-to-user platforms will also need to take steps to reduce risks that their services are used to perpetrate offences. These duties extend to the unlawful supply, or offer to supply, of controlled drugs. Platforms and Search services will need to take steps to prevent users encountering illegal sale of drugs content via their services. Platforms will need to remove this content when it does appear.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 1 Lack of available care providers and carers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Carl Anthony OWSTON · 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
Carl Owston died at home on 10 January 2023 from sudden unexplained death in alcohol misuse with steatosis and steatohepatitis. A care package commissioned for him could not be provided because no care provider was available, raising concern that shortages of carers and care providers may result in people not receiving needed care, with potentially fatal results.
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 available care providers and carers
Wider context from the report “Mr. Owston had a Care Package commissioned for him by Brighton and Hove City Council. They were unable to find a Care provider willing to provide the service due to a shortage of care providers and carers nationwide. The lack of carers and care providers could well lead to people in future not receiving the care they need with fatal results.
” 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 Make additional funding available to increase adult social care capacity, improve workforce recruitment and retention, reduce waiting times, and increase provider fee rates.
Verbatim wording from the response “Firstly, the government has made available up to £8.6 billion in additional funding over this financial year and next to support adult social care and discharge. This includes the Market Sustainability and Improvement Fund (MSIF) and the MSIF Workforce Fund, which are worth almost £2 billion over two years and are designed to support local authorities to increase adult social care capacity by targeting improvements in workforce recruitment and retention, reduce waiting times and increase fee rates paid to providers in their local areas. The MSIF Workforce Fund includes a particular focus on workforce pay.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local authorities are responsible for understanding and planning local care-market needs because they are best placed to do so.
Verbatim wording from the response “Under the Care Act (2014), local authorities have the duty to promote the efficient and effective operation of their care market and deliver a range of care and support services to meet diverse local needs. They must have regard to current and future demand for care and support services and consider how providers will meet that demand, including through fostering a workforce with the appropriate skills. I understand that Brighton and Hove Council have plans to address the lack of care provision in their market, including the necessary accommodation, and accompanying care & support services for those with mental health needs.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 12 Unavailability of out-of-hours emergency endoscopy View source Upper GI Bleeding Management and Principles of Care guidance no longer fit for purpose View source Lack of clarity about when to call the Emergency Treatment Team View source Insufficient Emergency Department space for patient demand View source Insufficient doctors and nurses for Emergency Department patient demand View source Failure to adequately share investigation learning with practitioners View source Failure to sufficiently identify and action issues from investigation findings View source Failure to record triage of ambulance arrivals at the Emergency Department View source Failure to maintain consistent investigation report content View source Failure to admit ambulance patients promptly and return ambulances to active duty View source Ineffective triage of ambulance arrivals at the Emergency Department View source Lack of clarity about when to engage the Major Haemorrhage Pathway View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Vivienne Greener · 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
Vivienne Greener was taken by ambulance to Glan Clwyd Hospital after vomiting blood and died there on 20 March 2018 following a massive upper gastrointestinal haemorrhage. The report identified concerns including delayed admission and triage, delayed provision of blood products, failures to escalate and trigger haemorrhage pathways, insufficient staffing and the lack of out-of-hours emergency endoscopy.
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 out-of-hours emergency endoscopy
Wider context from the report “1. An out of hours emergency endoscopy is still not available at Glan Clwyd Hospital or in this area of North Wales as the provision has ‘collapsed’ at Wrexham Maelor Hospital, so no referrals can be made;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Upper GI Bleeding Management and Principles of Care guidance no longer fit for purpose
Wider context from the report “6. The Health Board’s Upper GI Bleeding Management and Principles of Care 2022 is no longer fit for purpose ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 about when to call the Emergency Treatment Team
Wider context from the report “4. There is not a clear understanding of when the Emergency Treatment Team should be called ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Emergency Department space for patient demand
Wider context from the report “2. There are insufficient doctors and nurses and space available to cope with the number of patients coming into the Emergency Department ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 doctors and nurses for Emergency Department patient demand
Wider context from the report “2. There are insufficient doctors and nurses and space available to cope with the number of patients coming into the Emergency Department;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 adequately share investigation learning with practitioners
Wider context from the report “7. Any learning from the Health Board’s Investigation Report is not adequately shared with its practitioners ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 sufficiently identify and action issues from investigation findings
Wider context from the report “8. A part of the Health Board’s Investigation Report changed in different versions and obscured the reason why the provision of blood products was delayed meaning issues are not sufficiently identified and actioned ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to record triage of ambulance arrivals at the Emergency Department
Wider context from the report “3. There is an ineffective triage and record of triage of patients arriving at Glan Clwyd Emergency Department by ambulance ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 consistent investigation report content
Wider context from the report “8. A part of the Health Board’s Investigation Report changed in different versions and obscured the reason why the provision of blood products was delayed meaning issues are not sufficiently identified and actioned;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 admit ambulance patients promptly and return ambulances to active duty
Wider context from the report “9. Ambulances and paramedics are being kept at the Emergency Department as an extension of the hospital and its staff , due to WAST being unable to get their patients admitted into the Emergency Department and back on active duty .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Ineffective triage of ambulance arrivals at the Emergency Department
Wider context from the report “3. There is an ineffective triage and record of triage of patients arriving at Glan Clwyd Emergency Department by ambulance ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 about when to engage the Major Haemorrhage Pathway
Wider context from the report “5. There is not a clear understanding of when the Major Haemorrhage Pathway should be engaged ;
” Open source report
Concerns raised 1 Inadequate community provision for the care and treatment of autistic people View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jessica Zoe EASTLAND-SEARES · 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
Jessie was pronounced deceased in hospital on 17 May 2022 after being found with a ligature around their neck, having been detained under the Mental Health Act and hospitalised since 4 March 2022. The report raises concerns about inadequate community provision for autistic people, including difficulties finding suitable support and the breakdown of temporary care arrangements before Jessie’s inpatient admission.
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 provision for the care and treatment of autistic people
Wider context from the report “Sadly this case exposes the total inadequate level of community provision for the care and treatment of those with suffering with Autism . This is a national problem and sadly leads to many experiencing unnecessary admissions into inpatient mental health facilities and also A&E attendances.
Despite a report from the Health and Social Care committee from 2021 this case showed that there does not seem to have been any real improvement and more lives are likely to be lost.
Reading from this report, it says “The conclusion of this report was that Autistic people (and people with learning disabilities) have the right to live independent, free and fulfilled lives in the community and it is an unacceptable violation of their human rights to deny them the chance to do so.”
The report identified that “the community support and provision for autistic people (and those with learning difficulties) and financial investment in those services is significantly below the level required to meet the needs of those individuals and to provide adequate support for them in the community. ”
The Inquest heard that two years on there still remains an acute shortage of provision . Evidence was heard that East Sussex Council had tried over 30 providers to help put in place support for Jessie but they could not find a placement for her so the only provision that they were able to offer was supported housing with temporary care agency staff. This provision broke down which exacerbated Jessie’s mental health. This then led to a Hosptial mental inpatient admission.
” 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 Invest an additional £121 million to improve community support for autistic people and people with learning disabilities.
Verbatim wording from the response “This financial year, we are investing an additional £121m to improve community support for autistic people and people with a learning disability, including funding for Children and Young People’s keyworkers. In addition, all Integrated Care Boards are expected to have an Executive Lead on learning disability and autism. This lead will support the board in planning to meet the needs of its local population of autistic people and people with a learning disability, and to have effective oversight of, and support improvements in, the quality of care for people in a mental health, learning disability and autism inpatient setting.” Source location Response from Department of Health and Social Care
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 Publish the updated draft Autism Act statutory guidance for public consultation.
Verbatim wording from the response “We are currently prioritising updating the Autism Act statutory guidance to support the NHS and local authorities to deliver improved outcomes for autistic people in line with the national Strategy. This will include setting out guidance on how local authorities can meet their responsibilities relating to social care provision for autistic adults. We expect to publish the updated draft Statutory Guidance for public consultation, this year.” Source location Response from Department of Health and Social Care
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 Update Autism Act statutory guidance to improve outcomes and clarify local authority responsibilities for autistic adults’ social care.
Verbatim wording from the response “We are currently prioritising updating the Autism Act statutory guidance to support the NHS and local authorities to deliver improved outcomes for autistic people in line with the national Strategy. This will include setting out guidance on how local authorities can meet their responsibilities relating to social care provision for autistic adults. We expect to publish the updated draft Statutory Guidance for public consultation, this year.” Source location Response from Department of Health and Social Care
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 commissioning standards to set clear expectations for good social care commissioning.
Verbatim wording from the response “That is why, in Next steps to put people at the heart of care, we committed to developing commissioning standards: to set clear expectations of what good commissioning looks like and to drive greater consistency across the country. We are also investing in a pilot training programme for senior local authority commissioners to help local areas with developing their skills in future-proofing their care markets and ensuring they have the data they need to shape their markets well.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest in pilot training for senior local authority commissioners to improve care-market planning and data use.
Verbatim wording from the response “That is why, in Next steps to put people at the heart of care, we committed to developing commissioning standards: to set clear expectations of what good commissioning looks like and to drive greater consistency across the country. We are also investing in a pilot training programme for senior local authority commissioners to help local areas with developing their skills in future-proofing their care markets and ensuring they have the data they need to shape their markets well.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor implementation of the Building the Right Support Action Plan through the cross-system Delivery Board.
Verbatim wording from the response “We are determined to reduce the number of people with a learning disability and autistic people in mental health hospitals by supporting people to live well in their communities. The Building the Right Support Action Plan (published July 2022, alongside our response to the Health and Social Care Committee Report ‘The treatment of autistic people and people with learning disabilities’), brings together a wide range of actions we are taking across government and public services to help us drive progress on this. The cross-system Building the Right Support Delivery Board that I chair, monitors implementation of the commitments contained in the Action Plan.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £15 million to establish ethical international recruitment support and bolster the adult social care workforce.
Verbatim wording from the response “• Providing £15m for the 2023/24 financial year to help local areas establish support arrangements for ethical international recruitment and bolster workforce in adult social care.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make care workers eligible for the Health and Care Worker Visa and add them to the Shortage Occupation List.
Verbatim wording from the response “• Making care workers eligible for the Health and Care Worker Visa and adding them to the Shortage Occupation list (February 2022).” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional adult social care funding to increase workforce capacity and retention, reduce waiting times and support provider fee rates.
Verbatim wording from the response “The government has now made available up to £8.6 billion in additional funding over this financial year and next year to support adult social care and discharge. This includes £500m announced in January which has specifically been made available to support local authorities with the cost of social care in 2024/25.” Source location Response from Department of Health and Social Care
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 Run the next phase of the national Made with Care recruitment campaign.
Verbatim wording from the response “This is in addition to the Government’s support to Local Authorities in addressing workforce pressures, including:” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest up to £700 million in workforce training, recognition and career progression to improve social care quality and outcomes.
Verbatim wording from the response “social care workforce remains at the heart of our reform plans. We are supporting care workers to develop their skills and their careers, alongside a range of new funded training schemes. In December 2021, we set out our strategy for the social care workforce in our ‘People at The Heart of Care’ white paper and in 2023 we published ‘Next Steps to put People at the Heart of Care’ which set out more detail on the government’s plans for reform. It outlined our plans to invest in better workforce training, recognition, and career progression. The ‘Next Steps to put People at the Heart of Care’ also set out how we are investing up to £700 million over this financial year and next, building on £100 million already invested in 2022/23, to improve the quality of social care provision and care outcomes.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local authorities are responsible for planning and shaping local care markets because they are best placed to understand local population needs.
Verbatim wording from the response “Under the Care Act (2014), local authorities have the duty to promote the efficient and effective operation of their care market, ensuring local care and support provision meets diverse local needs. They must have regard to current and future demand for care and support services and consider how providers will meet that demand. However, the Government recognises that shaping a care market is incredibly challenging. While local authorities are best placed to understand and plan for the care and support needs of their local population, there are elements of good market shaping practice that can be universally applied, such as involving those who draw upon care and their families in the commissioning process, supporting and investing in community services, and taking a prevention-based approach to shaping their market.” Source location Response from Department of Health and Social Care
Open published response
8 Dec 2023 WILLIAM BRIAN KIN GRAY · Prevention of Future Deaths report Essex
View report summary
Concerns raised 11 Failure of ambulance investigations to compare attendances and identify learning View source Failure to provide guidance on inflation pressure when securing a paediatric airway adjunct in life-threatening asthma View source Failure to assess, audit and plan for disruption to children’s asthma service access View source Under-resourcing of the asthma and allergy children’s service View source Failure of hospital paediatric doctors to recognise intramuscular adrenaline treatment for life-threatening asthma View source Failure of ambulance investigations to identify omitted emergency treatments and access View source Failure to incorporate investigation learning into training and alerts View source Lack of clear ambulance guidance for recognising and managing life-threatening childhood asthma and failed airway management View source Failure to involve children directly in asthma service consultations View source Limited availability of trained paediatric endotracheal intubation capability View source Non-mandatory asthma training for health professionals caring for children and young people View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
WILLIAM BRIAN KIN GRAY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William had poorly controlled asthma and experienced a life-threatening asthma attack on 29 May 2021, followed by respiratory and cardiac arrest and a brain injury not compatible with life. The report identified multiple concerns, including failures to assess, review, escalate and treat his asthma, ambulance treatment and airway-management issues, gaps in investigation and training, and limitations in asthma and emergency-care services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance investigations to compare attendances and identify learning
Wider context from the report “(3) Learning and sharing lessons learned is a function of investigation. The Trust investigation report did not:
(a) scrutinise the ambulance attendance to William on 27 October 2020 in comparison to the attendance on 29 May 2021 and missed an opportunity to understand :
i. the timeliness of the administration of adrenalin during a life-threatening asthma attack in accordance with the JRCALC guidelines and that there may be additional training needs. Two paramedics attended both on 27 October 2020 and 29 May 2021 but did not consider the administration of intramuscular adrenalin on the second occasion.
ii. Whilst life-threatening asthma in children is an extremely rare call, the same two paramedics attended on 27 October and 29 May and initial treatment given differed during a life-threatening asthma attack
iii. that ambulance crew focused on the airway to exclusion of other treatment options and did not recognise the significant amount of inflation pressures that are required to manage the airway of an asthmatic child in respiratory arrest. Crew were misled in thinking that the airway adjunct equipment was not the correct size as a consequence, and were swapping the adjuncts
iv. that the same paramedic was left managing an airway throughout the arrest despite the arrival of more experienced colleagues that arrived as backup, including an LMO until HEMS took over.
The Trust did not address the issues at 3 (a) i-iv above in their annual training following William’s death and no alerts or learning notes have been circulated.
(b) East of England Ambulance NHS Trust investigation did not identify a number of risks and omissions its investigation of this child death:
i. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
ii. Intramuscular adrenalin was not administered for life threatening asthma for a child in respiratory arrest in accordance with JRCALC
iii. Intravenous adrenalin was not given or attempted when the patient went into cardiac arrest in accordance with the resuscitation guidelines and Intraosseous access was not attempted for a child in cardiac arrest for at least 10 minutes and only when the patient was in the ambulance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 guidance on inflation pressure when securing a paediatric airway adjunct in life-threatening asthma
Wider context from the report “(2) Life threatening childhood asthma is a rare occurrence for ambulance paramedics and the Joint Royal Colleges Ambulances Liaison Committee (JRCALC) Guidelines sets out treatment for it, however as paramedics rarely attend:
a. Clarity is required on what should be categorised as a life-threatening asthma. With guidance to enter the algorithm immediately to administer intramuscular adrenalin the purpose being to avoid cardiac arrest. Paramedics are more familiar with administration of intravenous adrenaline during resuscitation once cardiac arrest has occurred
b. does not contain clear guidance or advice on what to do when crew cannot ventilate, cannot oxygenate, or cannot intubate
c. when to abort repeated unsuccessful attempts to secure an airway and progress to hospital
d. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to assess, audit and plan for disruption to children’s asthma service access
Wider context from the report “(6) The Asthma & Allergy Childrens and Young Persons Service (the Service)
a. At the time of William’s initial referral to the Service in 2018 this consisted of one nurse for approximately 2000 children, and this increased to two nurses in November 2020. The evidence heard is that whilst the number of nurses has increased so has the geographical area that the Service covers, and that there are ongoing plans to increase this further. The Service remains under resourced whilst attempting to expand.
b. The Service continued to operate during the pandemic and did not introduce video calls when they could not make face-to-face attendances . There was no risk assessment of the impact on the Service , and no audit of whether this was sufficient to manage the Service . There is no contingency plan in place should this issue arise again .
c. The Service relied on telephone contact Nurses did not speak to William although he was old enough to be involved in his care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Under-resourcing of the asthma and allergy children’s service
Wider context from the report “(6) The Asthma & Allergy Childrens and Young Persons Service (the Service)
a. At the time of William’s initial referral to the Service in 2018 this consisted of one nurse for approximately 2000 children, and this increased to two nurses in November 2020. The evidence heard is that whilst the number of nurses has increased so has the geographical area that the Service covers, and that there are ongoing plans to increase this further. The Service remains under resourced whilst attempting to expand .
b. The Service continued to operate during the pandemic and did not introduce video calls when they could not make face-to-face attendances. There was no risk assessment of the impact on the Service, and no audit of whether this was sufficient to manage the Service. There is no contingency plan in place should this issue arise again.
c. The Service relied on telephone contact Nurses did not speak to William although he was old enough to be involved in his care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital paediatric doctors to recognise intramuscular adrenaline treatment for life-threatening asthma
Wider context from the report “(1) Experienced hospital paediatric doctors all gave evidence that they were unaware that administration of intramuscular adrenaline by paramedics is part of the Joint Royal Colleges Ambulances Liaison Committee JRCALC protocol for life-threatening asthma . The beneficial effects of the administration adrenalin was not considered , William’s presentation on arrival at hospital was falsely reassuring.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance investigations to identify omitted emergency treatments and access
Wider context from the report “(3) Learning and sharing lessons learned is a function of investigation. The Trust investigation report did not:
(a) scrutinise the ambulance attendance to William on 27 October 2020 in comparison to the attendance on 29 May 2021 and missed an opportunity to understand:
i. the timeliness of the administration of adrenalin during a life-threatening asthma attack in accordance with the JRCALC guidelines and that there may be additional training needs. Two paramedics attended both on 27 October 2020 and 29 May 2021 but did not consider the administration of intramuscular adrenalin on the second occasion.
ii. Whilst life-threatening asthma in children is an extremely rare call, the same two paramedics attended on 27 October and 29 May and initial treatment given differed during a life-threatening asthma attack
iii. that ambulance crew focused on the airway to exclusion of other treatment options and did not recognise the significant amount of inflation pressures that are required to manage the airway of an asthmatic child in respiratory arrest. Crew were misled in thinking that the airway adjunct equipment was not the correct size as a consequence, and were swapping the adjuncts
iv. that the same paramedic was left managing an airway throughout the arrest despite the arrival of more experienced colleagues that arrived as backup, including an LMO until HEMS took over.
The Trust did not address the issues at 3 (a) i-iv above in their annual training following William’s death and no alerts or learning notes have been circulated.
(b) East of England Ambulance NHS Trust investigation did not identify a number of risks and omissions its investigation of this child death:
i. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
ii. Intramuscular adrenalin was not administered for life threatening asthma for a child in respiratory arrest in accordance with JRCALC
iii. Intravenous adrenalin was not given or attempted when the patient went into cardiac arrest in accordance with the resuscitation guidelines and Intraosseous access was not attempted for a child in cardiac arrest for at least 10 minutes and only when the patient was in the ambulance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 incorporate investigation learning into training and alerts
Wider context from the report “(3) Learning and sharing lessons learned is a function of investigation. The Trust investigation report did not:
(a) scrutinise the ambulance attendance to William on 27 October 2020 in comparison to the attendance on 29 May 2021 and missed an opportunity to understand:
i. the timeliness of the administration of adrenalin during a life-threatening asthma attack in accordance with the JRCALC guidelines and that there may be additional training needs. Two paramedics attended both on 27 October 2020 and 29 May 2021 but did not consider the administration of intramuscular adrenalin on the second occasion.
ii. Whilst life-threatening asthma in children is an extremely rare call, the same two paramedics attended on 27 October and 29 May and initial treatment given differed during a life-threatening asthma attack
iii. that ambulance crew focused on the airway to exclusion of other treatment options and did not recognise the significant amount of inflation pressures that are required to manage the airway of an asthmatic child in respiratory arrest. Crew were misled in thinking that the airway adjunct equipment was not the correct size as a consequence, and were swapping the adjuncts
iv. that the same paramedic was left managing an airway throughout the arrest despite the arrival of more experienced colleagues that arrived as backup, including an LMO until HEMS took over.
The Trust did not address the issues at 3 (a) i-iv above in their annual training following William’s death and no alerts or learning notes have been circulated .
(b) East of England Ambulance NHS Trust investigation did not identify a number of risks and omissions its investigation of this child death:
i. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
ii. Intramuscular adrenalin was not administered for life threatening asthma for a child in respiratory arrest in accordance with JRCALC
iii. Intravenous adrenalin was not given or attempted when the patient went into cardiac arrest in accordance with the resuscitation guidelines and Intraosseous access was not attempted for a child in cardiac arrest for at least 10 minutes and only when the patient was in the ambulance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clear ambulance guidance for recognising and managing life-threatening childhood asthma and failed airway management
Wider context from the report “(2) Life threatening childhood asthma is a rare occurrence for ambulance paramedics and the Joint Royal Colleges Ambulances Liaison Committee (JRCALC) Guidelines sets out treatment for it, however as paramedics rarely attend:
a. Clarity is required on what should be categorised as a life-threatening asthma. With guidance to enter the algorithm immediately to administer intramuscular adrenalin the purpose being to avoid cardiac arrest. Paramedics are more familiar with administration of intravenous adrenaline during resuscitation once cardiac arrest has occurred
b. does not contain clear guidance or advice on what to do when crew cannot ventilate, cannot oxygenate, or cannot intubate
c. when to abort repeated unsuccessful attempts to secure an airway and progress to hospital
d. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 involve children directly in asthma service consultations
Wider context from the report “(6) The Asthma & Allergy Childrens and Young Persons Service (the Service)
a. At the time of William’s initial referral to the Service in 2018 this consisted of one nurse for approximately 2000 children, and this increased to two nurses in November 2020. The evidence heard is that whilst the number of nurses has increased so has the geographical area that the Service covers, and that there are ongoing plans to increase this further. The Service remains under resourced whilst attempting to expand.
b. The Service continued to operate during the pandemic and did not introduce video calls when they could not make face-to-face attendances. There was no risk assessment of the impact on the Service, and no audit of whether this was sufficient to manage the Service. There is no contingency plan in place should this issue arise again.
c. The Service relied on telephone contact Nurses did not speak to William although he was old enough to be involved in his care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Limited availability of trained paediatric endotracheal intubation capability
Wider context from the report “(4) The Trust issued a Clinical Instruction on 17 September 2020 that paramedics must not insert endotracheal tubes as a safety measure to avoid adverse incidents as there was a difficulty in keeping paramedics skills up to a level of competency. Evidence was heard that the Trust has since revised its policy and reintroduced endotracheal intubation for a specialist cohort of paramedic crew:
i. The Trust treatment for those aged 12 and over permits endotracheal intubation by those ambulance crew with specialist qualifications however, they cannot intubate children under 12 who are entirely reliant on HEMS arriving in sufficient time if the airway cannot be sufficiently managed.
ii. Essex is a large county and there are very few paramedics trained on any one shift to provide endotracheal intubation
iii. there is a difference in provision of life-saving treatment in Essex between those over 12 and for children under 12 and HEMS is a charity with very limited resource across a very large county .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Non-mandatory asthma training for health professionals caring for children and young people
Wider context from the report “(5) Training for health professionals who care for children and young people is not mandatory
The National Capabilities Framework for Professionals who care for Children and Young People with Asthma (NHS Health Education England) contains tiers of training and national capabilities but is not mandatory
” 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 Health system employers are responsible for ensuring staff training meets required standards and allows time for continuing professional development.
Verbatim wording from the response “Employers in the health system are responsible for ensuring that their staff are trained to the required standards to deliver appropriate treatment for patients and for ensuring that staff have appropriate time to undertake continuous professional development. Health Education England (now part of NHS England) published The National Capabilities Framework for Professionals who care for Children and Young People with Asthma with a range of training programmes for people to use.” Source location Response from Department of Health and Social Care
Open published response
2 Dec 2023 Steven Bowker · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Dangers to patients from prolonged prescription and use of opiate medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Steven Bowker · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Steven Bowker fell from garden ladders in 2016 and subsequently developed dependence on prescribed opioid medication. He was found unresponsive at home and pronounced dead on 1 December 2021; the report expressed concern about the dangers of prolonged prescription and use of opiate medication.
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 Dangers to patients from prolonged prescription and use of opiate medication
Wider context from the report “I am concerned by the dangers to patients in respect of the prolonged prescription and use of opiate medication .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prescribing and medication review decisions are assigned to individual clinicians, working with patients and accountable to service commissioners.
Verbatim wording from the response “I hope you will appreciate and understand, that the decision to prescribe a particular product is, rightly, a clinical one and should be based on the patient’s medical needs. GPs and clinicians are expected to take into account regulatory and good practice guidance, appropriate local and national guidance on clinical, and cost effectiveness and treatment pathways of their respective Integrated Care Board (ICB). They are accountable for their prescribing decisions, both professionally and to their service commissioners. Similarly, the process of reviewing medication is one in which the GP or responsible clinician work together with the patient to decide on the most appropriate course of treatment. Prescribing clinicians should always satisfy themselves that the medicines they consider appropriate for their patients can be safely prescribed.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 3 Delays in offloading ambulance patients at hospitals View source Lack of ambulance service capacity to respond to emergency call demand View source Delays in ambulance responses to Category 2 calls View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David John Briggs · 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
David John Briggs died at the Northern General Hospital, Sheffield, on 15 November 2022 after developing urosepsis associated with urinary tract obstruction and a long-term catheter. His carers made several emergency calls as his breathing deteriorated, but the ambulance arrived at 0044 after the first call at 2049. Concerns included insufficient ambulance service resources, delays in responding to the Category 2 call, and hospital offloading delays that reduced ambulance availability.
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 offloading ambulance patients at hospitals
Wider context from the report “(3) There was a significant delay in offloading patients at hospitals which tied up ambulance resource and meant they were unable to respond to emergency calls.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 ambulance service capacity to respond to emergency call demand
Wider context from the report “(2) YAS were not resourced to respond to the number of emergency calls.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 ambulance responses to Category 2 calls
Wider context from the report “(1) The ambulance service was called at 2049 on 14 November 2022 and the call was graded as a Category 2 call requiring a response within 40 minutes. The ambulance finally arrived at 0044 on 15 November 2022.
” 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 Deliver 5,000 additional staffed, permanent hospital beds and maintain this capacity uplift in 2024/25.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £1.6 billion over two years to support timely and effective hospital discharge.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
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 Deliver new ambulances and specialist mental health vehicles.
Verbatim wording from the response “million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with NHS England to reduce ambulance response times.
Verbatim wording from the response “However, I recognise there is still more to do to reduce response times further, and the Government will continue to work with NHS England to achieve this.” Source location Response from Department of Health and Social Care
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 Scale up national virtual ward capacity to more than 10,000 beds.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
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 Publish the delivery plan for recovering urgent and emergency care services.
Verbatim wording from the response “As the Minister responsible for urgent and emergency care services, I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times. Our ambitions for this year include reducing Category 2 ambulance response times to 30 minutes on average across this fiscal year. The plan is available at https://www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain additional ambulance capacity funded to improve response times during 2024/25.
Verbatim wording from the response “Your report highlights that YAS were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local action to improve ambulance response and patient handover times is assigned to South Yorkshire Integrated Care Board, as best placed to respond.
Verbatim wording from the response “Your report raised concerns about the capacity of Yorkshire Ambulance NHS Trust (YAS). You have appropriately shared your report and concerns with South Yorkshire Integrated Care Board, who are best placed to respond on the action being taken locally to improve ambulance response and patient handover times.” Source location Response from Department of Health and Social Care
Open published response
27 Nov 2023 Glyn Ackerley · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1 Failure to risk-stratify high-risk overdoses for immediate clinical response 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
Glyn Ackerley · 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
Glyn Ackerley became unresponsive at home on 4 September 2022 after reporting that he had swallowed medication; the cause of death could not be determined. The report raised concern that the NHS Pathways process in place at the time did not distinguish between high-risk and low-risk overdoses, potentially delaying treatment for a potentially fatal overdose.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to risk-stratify high-risk overdoses for immediate clinical response
Wider context from the report “The current NHS Pathways process does not differentiate between a high risk and low risk overdose, categorising all such calls without additional symptoms as category 3. Evidence was heard during the inquest that time is of the essence when dealing with an opiate overdose, and giving reversal medication prior to any respiratory depression or cardiac arrest will likely have a better outcome. In light of the concerns raised by this case, NWAS have reviewed their process and added in additional questions for call handlers to identify high risk medications involved in an overdose, which they then automatically categorise as a category 2 and send for a call back from a clinician immediately.
NWAS gave evidence in writing that they had raised the concern and their suggested management with the National NHS Pathways team on 6 April 2023, with the result that the national team would continue to review the process but with clinical review in 15 minutes and high risk medications being upgraded to category 2. It is unclear from the evidence whether this is a proposed change to the process in place in September 2022 which would mean Mr Ackerley would have had a category 2 response at 21.48, or whether the system remains the same. If the system is not for a category 2 response for high risk medication, it is my concern that this will not allow for prompt treatment of those who have taken a potentially fatal overdose.
” Open source report
27 Nov 2023 Boycie [Alexander/Chatterton] · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1 Lack of a properly managed and funded national register for TOF cases 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
Boycie [Alexander/Chatterton] · 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
Boycie was born at 36 weeks and 6 days with congenital oesophageal atresia and tracheo-oesophageal fistula, underwent three planned surgical procedures, and died after developing respiratory complications following the third procedure. Experts expressed concern that treatment would be better supported by a properly managed and funded national register for tracheo-oesophageal fistula cases, which they considered likely to improve outcomes and survival rates.
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 properly managed and funded national register for TOF cases
Wider context from the report “1. I heard from experts giving evidence that the treatment of conditions such as OA with or without TOF would be better served by a properly managed and funded national register for TOF cases , which would in their view likely serve to improve outcomes and survival rates going forward.
” Open source report
27 Nov 2023 Barbara Jean Rymell · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 1 Insufficient English proficiency among direct care staff to communicate urgent medical needs and summon emergency help 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
Barbara Jean Rymell · 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
Barbara Jean Rymell, a frail elderly resident with dementia and mobility limitations, was left unattended on a mechanical stairlift at her care home on 8 August 2022. She left the stairlift, attempted to climb the stairs, fell, and became entrapped with her head under the stairlift chair; she was pronounced deceased when paramedics arrived. The report raises concerns about staff leaving vulnerable residents unattended and about care workers’ English proficiency affecting their ability to communicate the nature of an emergency and obtain appropriate medical assistance.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient English proficiency among direct care staff to communicate urgent medical needs and summon emergency help
Wider context from the report “I am concerned that those working with vulnerable people who are in a position of trust and responsibility must be able to demonstrate a sufficient proficiency in English to enable them to summon appropriate emergency medical attention when needed . Vulnerable people, by very definition, are unable to often appreciate the need for help; take steps to keep themselves safe and/or summon help for themselves when they need it.
By being unable to speak the native language of England with any proficiency I am concerned that deaths will continue to arise where those who are young, disabled, suffering from a mental impairment or who are elderly and in need of urgent medical help will not have this summoned for them if those who are engaging with emergency professionals are unable to communicate effectively .
The Court looked at evidence of the B1 English test. Examples from the paper were as follows:
“I ________ that book last year” (options are bought, have bought, had bought)
“The town, ________ is very beautiful, has lots of parks” (options are which, where, what).
This level of comprehension is comparable to a KS2 curriculum being studied by Year 6 students sitting their SATS exam and appears to be wholly insufficient for those working in the direct care and protection of vulnerable people , as demonstrated in this case by carers who were alone (i.e. no English speaking members of staff on duty) being unable to explain to medical professionals the presenting condition of the patient .
” Open source report
Concerns raised 3 Difficulty recruiting to vacant hospital positions View source Burn-out among paramedics, nurses and doctors View source Failure to maintain timely ambulance access to the ED View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Charles Seagrove 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
The report concerns the deaths of John Charles Seagrove, Pauline Mary Humphris and Patricia Joan Steggles, following delays in emergency ambulance response and in handing patients over to hospital staff. The report raises concerns about worsening emergency department pressures, with ambulances waiting outside, and reported burnout and recruitment difficulties among healthcare staff. In Mrs Humphris’s case, the coroner found that ambulance and hospital admission delays may have contributed to the outcome; in Mrs Steggles’s case, the inquest heard that earlier hospital arrival would probably have led to survival.
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 Difficulty recruiting to vacant hospital positions
Wider context from the report “It was acknowledged in the evidence that matters had improved over the summer this year. What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks. I have spoken to the Medical Director at RCHT, ████████, and he has confirmed that is the current position. This concern is compounded by the recognition that we are yet to experience the additional pressures that winter will bring.
Additionally, I am now hearing evidence at inquest of ‘burn-out’ among paramedics, nurses and doctors. At the inquest into the death of Mrs Steggles, I was advised that the hospital is now finding it difficult to recruit to vacant positions .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Burn-out among paramedics, nurses and doctors
Wider context from the report “It was acknowledged in the evidence that matters had improved over the summer this year. What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks. I have spoken to the Medical Director at RCHT, ████████, and he has confirmed that is the current position. This concern is compounded by the recognition that we are yet to experience the additional pressures that winter will bring.
Additionally, I am now hearing evidence at inquest of ‘burn-out’ among paramedics, nurses and doctors . At the inquest into the death of Mrs Steggles, I was advised that the hospital is now finding it difficult to recruit to vacant positions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 timely ambulance access to the ED
Wider context from the report “It was acknowledged in the evidence that matters had improved over the summer this year. What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks . I have spoken to the Medical Director at RCHT, ████████, and he has confirmed that is the current position. This concern is compounded by the recognition that we are yet to experience the additional pressures that winter will bring.
Additionally, I am now hearing evidence at inquest of ‘burn-out’ among paramedics, nurses and doctors. At the inquest into the death of Mrs Steggles, I was advised that the hospital is now finding it difficult to recruit to vacant positions.
” 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 Deliver 5,000 additional staffed, permanent hospital beds and maintain the resulting capacity uplift.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
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 Scale up national virtual ward capacity to more than 11,000 available beds.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £1.6 billion over two years to support timely and effective hospital discharge.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specific local urgent and emergency care improvements are best addressed by SWAST, the hospital trust and the local Integrated Care Board.
Verbatim wording from the response “Your report raises concerns about the response time performance of the South Western Ambulance Service NHS Foundation Trust (SWAST), ambulances queueing as a result of patient handover delays at the Royal Cornwall Hospital, and the pressures being felt by paramedics, nurses and doctors. You have also raised these concerns with the ambulance service and the hospital trust, as well as with the local Integrated Care Board as copied interested parties. These NHS organisations are best placed to respond on the specific action being taken locally to improve urgent and emergency care services.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 1 Unavailability of timely out-of-hours in-person cardiologist assessment for patients with suspected cardiac problems 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
Charlotte Burton · 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
Charlotte Burton, who was 40 and recently postpartum, returned to hospital on 27 November 2020 with shortness of breath and coughing up blood. She later deteriorated, suffered a cardiac arrest and died from acute left ventricular failure associated with cardiomyopathy, morbid obesity and pre-eclampsia. The report identified delayed recognition and treatment of likely diastolic heart failure, delayed escalation, and limited out-of-hours access to cardiology assessment as concerns.
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 timely out-of-hours in-person cardiologist assessment for patients with suspected cardiac problems
Wider context from the report “1. The evidence indicates that there is a nationwide shortage of suitably trained Cardiologists and that, particularly in District General Hospital setting, this means that out of hours there is no provision for patients presenting with suspected cardiac problems to be assessed in person by a Cardiologist . The system is therefore reliant upon doctors of different specialities or cardiac nurses recognising the condition and the need for contact with specialist at a different Trust . This still does not allow for in person assessment unless there is a transfer which is not always possible due to the severity of the condition or cannot be achieved in a suitable timescale and this represents an ongoing risk of future deaths.
” Open source report
Concerns raised 4 Lack of social care provision delaying discharge of medically fit patients View source Delays in ambulance response times View source Seasonal increases in ambulance and hospital demand creating risk of life-threatening delays View source Excessive ambulance handover delays at hospitals 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
KENNETH HEARD · 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
Kenneth Heard suffered a major heart attack on 10 July 2022, but the ambulance responding to his 999 call arrived about eight hours later. He suffered a cardiac arrest at Royal Cornwall Hospital on 11 July 2022 and resuscitation was unsuccessful; the court found it more likely than not that he would have survived without the ambulance delay. The principal concerns were ambulance response and hospital handover delays, linked to pressure on services and insufficient social care provision, with continuing risks to life from these delays, particularly during winter 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 Lack of social care provision delaying discharge of medically fit patients
Wider context from the report “(7) Notwithstanding these mitigating measures, concern arises from present circumstances, in relation to handover delays across the region covered by SWAST and specifically at the two hospitals most commonly used by patients from Cornwall, Derriford Hospital in Plymouth and Treliske Hospital in Truro.
(8) The most recent data available is for August 2023, in which month across the region covered by SWAST the hospitals suffering the longest ambulance delays were Treliske, Derriford and Gloucester. The data indicated that operational resource hours lost due to handover delays in excess of 15 minutes was as follows:
5,107 hours lost at Derriford Hospital,
Average Handover Time per Incident (Hrs:Mins:Sec) 2:04:36
2,449 hours lost at Treliske Hospital,
Average Handover Time per Incident (Hrs:Mins:Sec) 1:01:13
(9) Response times during June, July and August 2023 were heavily impacted by the handover delay pressures. The best response times were delivered on the weeks with the lowest hours lost to handover delays. The data for time lost due to handover delays at Derriford and RCHT in June, July and August 2023 are set out below.
Operational Resource Hours Lost to Handover Delays in Excess of 15 Minutes
Time Lost in June 2023
Time Lost in July 2023
Time Lost in August 2023
Derriford Hospital 4714:17 3436:41 5107:36
Treliske Hospital 2833:15 2386:23 2449:47
(10) By comparison the court was informed that before the pandemic the average number of hours lost due to handover delays was approximately 4,000 hours per month across the whole of the SWAST region. During 2022 the average number of hours lost due to handover delays was approximately 25,000 hours per month across the whole of SWAST. The worst month of last year was December 2022. The number of hours lost due to handover delays in that month across the whole of SWAST region, was approximately 35,000.
(11) The court heard evidence that there are future circumstances creating a concern of a risk to life, namely the seasonal nature of demands on SWAST. The winter months are likely to see an increase in demand for ambulance services and for hospital beds. December 2022 was the most demanding month of last year and featured the longest delays in response and handover. December 2023 is likely to be the most demanding month of this year.
(12) The root cause for ambulance delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes . It was acknowledged and accepted by NHS representatives at Inquest that Treliske and Derriford are unable to discharge otherwise medically fit patients due to the lack of social care provision . This means that wards are accommodating patients who would otherwise be discharged . The hospital wards being full beyond capacity , means that emergency departments are unable to move patients out of emergency beds into the wards . This means in turn that the emergency department is full and unable to receive patients from ambulances . This leads to the handover delays, and consequently response delays, documented in the data set out above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 ambulance response times
Wider context from the report “(7) Notwithstanding these mitigating measures, concern arises from present circumstances, in relation to handover delays across the region covered by SWAST and specifically at the two hospitals most commonly used by patients from Cornwall, Derriford Hospital in Plymouth and Treliske Hospital in Truro.
(8) The most recent data available is for August 2023, in which month across the region covered by SWAST the hospitals suffering the longest ambulance delays were Treliske, Derriford and Gloucester. The data indicated that operational resource hours lost due to handover delays in excess of 15 minutes was as follows:
5,107 hours lost at Derriford Hospital,
Average Handover Time per Incident (Hrs:Mins:Sec) 2:04:36
2,449 hours lost at Treliske Hospital,
Average Handover Time per Incident (Hrs:Mins:Sec) 1:01:13
(9) Response times during June, July and August 2023 were heavily impacted by the handover delay pressures . The best response times were delivered on the weeks with the lowest hours lost to handover delays . The data for time lost due to handover delays at Derriford and RCHT in June, July and August 2023 are set out below.
Operational Resource Hours Lost to Handover Delays in Excess of 15 Minutes
Time Lost in June 2023
Time Lost in July 2023
Time Lost in August 2023
Derriford Hospital 4714:17 3436:41 5107:36
Treliske Hospital 2833:15 2386:23 2449:47
(10) By comparison the court was informed that before the pandemic the average number of hours lost due to handover delays was approximately 4,000 hours per month across the whole of the SWAST region. During 2022 the average number of hours lost due to handover delays was approximately 25,000 hours per month across the whole of SWAST. The worst month of last year was December 2022. The number of hours lost due to handover delays in that month across the whole of SWAST region, was approximately 35,000.
(11) The court heard evidence that there are future circumstances creating a concern of a risk to life, namely the seasonal nature of demands on SWAST. The winter months are likely to see an increase in demand for ambulance services and for hospital beds. December 2022 was the most demanding month of last year and featured the longest delays in response and handover. December 2023 is likely to be the most demanding month of this year.
(12) The root cause for ambulance delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes. It was acknowledged and accepted by NHS representatives at Inquest that Treliske and Derriford are unable to discharge otherwise medically fit patients due to the lack of social care provision. This means that wards are accommodating patients who would otherwise be discharged. The hospital wards being full beyond capacity, means that emergency departments are unable to move patients out of emergency beds into the wards. This means in turn that the emergency department is full and unable to receive patients from ambulances. This leads to the handover delays, and consequently response delays, documented in the data set out above .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Seasonal increases in ambulance and hospital demand creating risk of life-threatening delays
Wider context from the report “(7) Notwithstanding these mitigating measures, concern arises from present circumstances, in relation to handover delays across the region covered by SWAST and specifically at the two hospitals most commonly used by patients from Cornwall, Derriford Hospital in Plymouth and Treliske Hospital in Truro.
(8) The most recent data available is for August 2023, in which month across the region covered by SWAST the hospitals suffering the longest ambulance delays were Treliske, Derriford and Gloucester. The data indicated that operational resource hours lost due to handover delays in excess of 15 minutes was as follows:
5,107 hours lost at Derriford Hospital,
Average Handover Time per Incident (Hrs:Mins:Sec) 2:04:36
2,449 hours lost at Treliske Hospital,
Average Handover Time per Incident (Hrs:Mins:Sec) 1:01:13
(9) Response times during June, July and August 2023 were heavily impacted by the handover delay pressures. The best response times were delivered on the weeks with the lowest hours lost to handover delays. The data for time lost due to handover delays at Derriford and RCHT in June, July and August 2023 are set out below.
Operational Resource Hours Lost to Handover Delays in Excess of 15 Minutes
Time Lost in June 2023
Time Lost in July 2023
Time Lost in August 2023
Derriford Hospital 4714:17 3436:41 5107:36
Treliske Hospital 2833:15 2386:23 2449:47
(10) By comparison the court was informed that before the pandemic the average number of hours lost due to handover delays was approximately 4,000 hours per month across the whole of the SWAST region. During 2022 the average number of hours lost due to handover delays was approximately 25,000 hours per month across the whole of SWAST. The worst month of last year was December 2022. The number of hours lost due to handover delays in that month across the whole of SWAST region, was approximately 35,000.
(11) The court heard evidence that there are future circumstances creating a concern of a risk to life, namely the seasonal nature of demands on SWAST . The winter months are likely to see an increase in demand for ambulance services and for hospital beds . December 2022 was the most demanding month of last year and featured the longest delays in response and handover . December 2023 is likely to be the most demanding month of this year.
(12) The root cause for ambulance delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes. It was acknowledged and accepted by NHS representatives at Inquest that Treliske and Derriford are unable to discharge otherwise medically fit patients due to the lack of social care provision. This means that wards are accommodating patients who would otherwise be discharged. The hospital wards being full beyond capacity, means that emergency departments are unable to move patients out of emergency beds into the wards. This means in turn that the emergency department is full and unable to receive patients from ambulances. This leads to the handover delays, and consequently response delays, documented in the data set out above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 ambulance handover delays at hospitals
Wider context from the report “(7) Notwithstanding these mitigating measures, concern arises from present circumstances, in relation to handover delays across the region covered by SWAST and specifically at the two hospitals most commonly used by patients from Cornwall, Derriford Hospital in Plymouth and Treliske Hospital in Truro.
(8) The most recent data available is for August 2023, in which month across the region covered by SWAST the hospitals suffering the longest ambulance delays were Treliske, Derriford and Gloucester. The data indicated that operational resource hours lost due to handover delays in excess of 15 minutes was as follows:
5,107 hours lost at Derriford Hospital ,
Average Handover Time per Incident (Hrs:Mins:Sec) 2:04:36
2,449 hours lost at Treliske Hospital ,
Average Handover Time per Incident (Hrs:Mins:Sec) 1:01:13
(9) Response times during June, July and August 2023 were heavily impacted by the handover delay pressures. The best response times were delivered on the weeks with the lowest hours lost to handover delays. The data for time lost due to handover delays at Derriford and RCHT in June, July and August 2023 are set out below.
Operational Resource Hours Lost to Handover Delays in Excess of 15 Minutes
Time Lost in June 2023
Time Lost in July 2023
Time Lost in August 2023
Derriford Hospital 4714:17 3436:41 5107:36
Treliske Hospital 2833:15 2386:23 2449:47
(10) By comparison the court was informed that before the pandemic the average number of hours lost due to handover delays was approximately 4,000 hours per month across the whole of the SWAST region. During 2022 the average number of hours lost due to handover delays was approximately 25,000 hours per month across the whole of SWAST . The worst month of last year was December 2022. The number of hours lost due to handover delays in that month across the whole of SWAST region, was approximately 35,000 .
(11) The court heard evidence that there are future circumstances creating a concern of a risk to life, namely the seasonal nature of demands on SWAST. The winter months are likely to see an increase in demand for ambulance services and for hospital beds. December 2022 was the most demanding month of last year and featured the longest delays in response and handover. December 2023 is likely to be the most demanding month of this year.
(12) The root cause for ambulance delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes. It was acknowledged and accepted by NHS representatives at Inquest that Treliske and Derriford are unable to discharge otherwise medically fit patients due to the lack of social care provision. This means that wards are accommodating patients who would otherwise be discharged. The hospital wards being full beyond capacity, means that emergency departments are unable to move patients out of emergency beds into the wards. This means in turn that the emergency department is full and unable to receive patients from ambulances. This leads to the handover delays, and consequently response delays, documented in the data set out above.
” 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 Expand ambulance capacity through additional funding and maintain the additional capacity in 2024/25.
Verbatim wording from the response “Your report highlights that SWAST were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” Source location Response from Department of Health and Social Care
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 Deliver new ambulances and specialist mental health vehicles.
Verbatim wording from the response “Your report highlights that SWAST were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” Source location Response from Department of Health and Social Care
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 Publish the Delivery Plan for recovering urgent and emergency care services.
Verbatim wording from the response “As the Minister responsible for urgent and emergency care services, I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average across this fiscal year. The plan is available at https://www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf” Source location Response from Department of Health and Social Care
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 Deliver 5,000 additional staffed, permanent hospital beds and maintain the capacity uplift in 2024/25.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £1.6 billion over two years to support timely and effective hospital discharge.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
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 Scale up virtual ward capacity to more than 10,000 beds nationally.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation SWAST and Royal Cornwall Hospital are best placed to respond on continuing local action to reduce handover delays and improve ambulance response times.
Verbatim wording from the response “Your report raised concerns about ambulance response times by South Western Ambulance Service NHS Foundation Trust (SWAST) and handover delays across the region. You have appropriately shared your report and concerns with SWAST and Royal Cornwall Hospital. SWAST and Royal Cornwall Hospital NHS Trust (RCHT), who are best placed to respond on the specific action they are continuing to take locally to reduce handover delays and improve ambulance response times.” Source location Response from Department of Health and Social Care
Open published response
23 Nov 2023 Philip Laurence Justin MALONE · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Unsafe exceptional process for creating psychiatric bed capacity through discharge of current patients View source Inadequate psychiatric bed capacity in Birmingham and Solihull View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Philip Laurence Justin MALONE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Philip Laurence Justin Malone, who had treatment-resistant schizophrenia and had deteriorated significantly in late June 2023, was found deceased in his supported accommodation on 3 July 2023. The inquest concluded that his death was the consequence of suicide. The principal concern was inadequate psychiatric bed capacity in Birmingham and Solihull, after clinicians sought to admit him but no inpatient bed was available, creating an ongoing risk of future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unsafe exceptional process for creating psychiatric bed capacity through discharge of current patients
Wider context from the report “1. Despite recognising Mr Malone needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity, BSMHFT’ RCA report identified no remedial action.
2. The Patient Safety Manager ████████ gave evidence that the lack of psychiatric bed capacity remains an ongoing problem and has not been resolved, and there is a genuine risk of the same problem with another patient in the future.
3. ████████ added there was an exceptional process, which required a considered decision at a high level, to make a bed available through identifying someone currently occupying a bed space to be discharged . In my view, this process is unsatisfactory as it creates a different set of risks around the patient being discharged , and amplifies the chronic shortage of beds.
4. There was reference to two preceding Regulation 28 Reports to Prevent Future Deaths (both available publicly on the judiciary website) that focussed on the chronic lack of mental health resources in Birmingham and Solihull. In relation to the specific issue of a lack of psychiatric bed capacity, in the case of Peter Fleming (no bed was available in August 2022) BSMHFT’s response (September 2023) referred to their response in the earlier case of Leroy Hamilton (no bed was available in December 2021). This response (April 2023) stated more resources had been obtained and a collaborative plan had been implemented with NHS Birmingham and Solihull Integrated Care Board.
The issue of adequately funding psychiatric beds is a local and national issue. Locally, BSMHFT require their commissioners to provide the necessary funding.
My principal concern is that the above dates indicate available psychiatric bed capacity in Birmingham and Solihull remains inadequate. Whilst some action may have been taken it is insufficient to resolve the problem. It follows there is a genuine risk of future deaths directly connected to a shortage of psychiatric bed spaces in Birmingham and Solihull unless further action is taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate psychiatric bed capacity in Birmingham and Solihull
Wider context from the report “1. Despite recognising Mr Malone needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity, BSMHFT’ RCA report identified no remedial action.
2. The Patient Safety Manager ████████ gave evidence that the lack of psychiatric bed capacity remains an ongoing problem and has not been resolved , and there is a genuine risk of the same problem with another patient in the future.
3. ████████ added there was an exceptional process, which required a considered decision at a high level, to make a bed available through identifying someone currently occupying a bed space to be discharged. In my view, this process is unsatisfactory as it creates a different set of risks around the patient being discharged, and amplifies the chronic shortage of beds.
4. There was reference to two preceding Regulation 28 Reports to Prevent Future Deaths (both available publicly on the judiciary website) that focussed on the chronic lack of mental health resources in Birmingham and Solihull. In relation to the specific issue of a lack of psychiatric bed capacity, in the case of Peter Fleming (no bed was available in August 2022) BSMHFT’s response (September 2023) referred to their response in the earlier case of Leroy Hamilton (no bed was available in December 2021). This response (April 2023) stated more resources had been obtained and a collaborative plan had been implemented with NHS Birmingham and Solihull Integrated Care Board.
The issue of adequately funding psychiatric beds is a local and national issue. Locally, BSMHFT require their commissioners to provide the necessary funding.
My principal concern is that the above dates indicate available psychiatric bed capacity in Birmingham and Solihull remains inadequate . Whilst some action may have been taken it is insufficient to resolve the problem . It follows there is a genuine risk of future deaths directly connected to a shortage of psychiatric bed spaces in Birmingham and Solihull unless further action is taken.
” 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 Expand funding for community mental health services nationwide to help manage pressure on inpatient beds.
Verbatim wording from the response “At a national level, through the NHS Long Term Plan we have provided record levels of investment to expand and transform NHS mental health services and increase the workforce. The long-term aim set out within the Plan is to improve community support for those with serious mental illness to avoid the need for an inpatient admission where possible. We are set to reach nearly £1 billion additional funding invested by 2023/24 (compared to 2018/19) to transform community mental health services. However, we recognise that community-based care will not always be appropriate for those with more complex needs. Major expansion in funding for community mental health services commenced in all areas in 2021/22, which has been key to managing pressures on inpatient beds.” Source location Response from Department of Health and Social Care
Open published response
17 Nov 2023 Raymond Lionel Eggleton · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 2 Failure to complete initial falls risk assessments using all available information View source Failure to dynamically provide enhanced supervision for changing patient needs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Raymond Lionel Eggleton · 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
Raymond Lionel Eggleton died in hospital on 25 January 2023 after falling on a medical unit, sustaining a fractured neck of femur and head injuries, and subsequently developing dysphagia, immobility, delirium and aspiration pneumonia. The principal concerns were that his falls risk assessment did not use all available information about his previous falls and postural hypotension, resulting in inadequate supervision, and that the ward lacked sufficient flexibility and resilience to respond dynamically to vulnerable patients’ enhanced care needs, particularly during night shifts.
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 complete initial falls risk assessments using all available information
Wider context from the report “During the course of the Inquest, I also heard evidence from Sister Jones and in addition to the challenge of getting the staffing levels commensurate to the patients needs and safeguarding patients there does appear to be an issue that causes me a concern as regards the ability to dynamically respond to a need for enhanced supervision especially entering into night shifts. Sister Jones when questioned was open and extremely candid in her answer that at those times nursing staff could not always support those additional needs in the short term because of the challenge to get additional personal at short notice in circumstances where the nursing team were under pressure due to the complexities and demands of patient’s needs. There is in my view no flexibility and resilience within the system to dynamically adapt and respond to changing patients enhanced needs exacerbated by the fact that especially during the winter months those beds are mainly occupied by the elderly. It is easier during day shifts to respond but there clearly appears to be an issue especially going into night shifts.
There were 2 issues here, firstly the initial falls risk assessment on LAMU which was not undertaken taking advantage of all available information which in my view led to an incorrect assessment of Ray’s supervision needs . His fall was observed by another member of the nursing staff and therefore my view is that only arm’s length supervision would have avoided the fall and that there were sufficient indicators on two occasions prior to the event occurring . The failure here in relation to the initial assessment was down to the volume of work and not in my view laziness or anything of that nature on the part of nursing staff.
Flowing from the first issue a further issue relates to the resilience and the ability to respond dynamically with changing patients on the ward so as to ensure that vulnerable patients with a high degree of risk of falling, like Ray, are properly safeguarded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 dynamically provide enhanced supervision for changing patient needs
Wider context from the report “During the course of the Inquest, I also heard evidence from Sister Jones and in addition to the challenge of getting the staffing levels commensurate to the patients needs and safeguarding patients there does appear to be an issue that causes me a concern as regards the ability to dynamically respond to a need for enhanced supervision especially entering into night shifts . Sister Jones when questioned was open and extremely candid in her answer that at those times nursing staff could not always support those additional needs in the short term because of the challenge to get additional personal at short notice in circumstances where the nursing team were under pressure due to the complexities and demands of patient’s needs. There is in my view no flexibility and resilience within the system to dynamically adapt and respond to changing patients enhanced needs exacerbated by the fact that especially during the winter months those beds are mainly occupied by the elderly. It is easier during day shifts to respond but there clearly appears to be an issue especially going into night shifts.
There were 2 issues here, firstly the initial falls risk assessment on LAMU which was not undertaken taking advantage of all available information which in my view led to an incorrect assessment of Ray’s supervision needs. His fall was observed by another member of the nursing staff and therefore my view is that only arm’s length supervision would have avoided the fall and that there were sufficient indicators on two occasions prior to the event occurring. The failure here in relation to the initial assessment was down to the volume of work and not in my view laziness or anything of that nature on the part of nursing staff.
Flowing from the first issue a further issue relates to the resilience and the ability to respond dynamically with changing patients on the ward so as to ensure that vulnerable patients with a high degree of risk of falling, like Ray, are properly safeguarded.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local clinical and other leaders are responsible for determining staffing levels and responding to local patient-safety needs.
Verbatim wording from the response “Safe staffing
Responsibility for staffing levels remains with clinical and other leaders at a local level, responding to local needs, supported by evidence-based guidelines by national and professional bodies and overseen and regulated in England by the CQC. Reaching the right staff numbers and mix should depend on an evidence-based approach and the exercise of real-time, risk-assessed, professional judgements by day-to-day leadership and a multi-professional approach.” Source location Response from Department of Health and Social Care
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