28 Apr 2023 Winbourne Gregory Charles · Prevention of Future Deaths report East London
View report summary
Concerns raised 15 Failure to provide accurate emergency-response information in incident reports View source Failure to incorporate available clinical information into self-harm risk assessments View source Failure to escalate suspension of patient observations through governance processes View source Failure to activate the ward emergency bell View source Failure of serious incident investigation to address risk-assessment and reporting deficiencies View source Failure to carry out prescribed patient observations View source Failure to maintain accurate and reliable observation records View source Failure to use the anti-barricade key to access a barricaded room View source Failure to align observation frequency decisions with policy guidance View source Unavailability of a ligature cutter for prompt emergency use View source Failure to provide paramedics with a clear and relevant patient history View source Delays in administering oxygen during emergencies View source Delays in calling duty doctors during emergencies View source Failure to identify and escalate observation suspension in the 72-hour report View source Failure to use the on-site defibrillator during an emergency View source See 12 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
Winbourne Gregory Charles · 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
Winbourne Gregory Charles was found unresponsive on 10 April 2021, suspended on a mental health ward, after being admitted under the Mental Health Act following an attempt to take his own life. The principal concerns included failures in risk assessment, observation practices, emergency response, record keeping, and governance processes.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate emergency-response information in incident reports
Wider context from the report “6. Governance process failings.
a. A datix incident report created on the evening of 10ᵗʰ April 2021 by a senior nurse and Modern Matron contained misleading information that suggested that emergency response policies were followed when in fact they were not .
b. The Datix failed to mention that observations had been suspended by the shift coordinator, a fact that was understood at that time. This obvious and significant piece of information that should have been escalated through the Trust governance team for action.
c. The Trust 72 hour report was written by the Modern Matron and was signed-off by an integrated care director on 15th April 2021. This document also failed to identify or escalate the significant issue of the suspension of observation at 16.00 on 10th April 2021.
d. The Trust SI report was not prepared to fully address the poor risk assessment or inadequate datix & 72 hr reports.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 available clinical information into self-harm risk assessments
Wider context from the report “1. A failure to adequately assess risk of harm - Poor record keeping and a failure to read electronic records meant that important information was not considered at a Multi-Disciplinary Team (“MDT”) ward round on 6ᵗʰ April 2021. The MDT arrived at a conclusion that Mr Charles’ risk of self-harm was “no risk”. A psychologist’s assessment on the clinical record that assessed Mr Charles risk of self-harm as high on 31/3/21 was neither read nor incorporated into the MDT discussion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 escalate suspension of patient observations through governance processes
Wider context from the report “6. Governance process failings.
a. A datix incident report created on the evening of 10ᵗʰ April 2021 by a senior nurse and Modern Matron contained misleading information that suggested that emergency response policies were followed when in fact they were not.
b. The Datix failed to mention that observations had been suspended by the shift coordinator , a fact that was understood at that time. This obvious and significant piece of information that should have been escalated through the Trust governance team for action .
c. The Trust 72 hour report was written by the Modern Matron and was signed-off by an integrated care director on 15th April 2021. This document also failed to identify or escalate the significant issue of the suspension of observation at 16.00 on 10th April 2021.
d. The Trust SI report was not prepared to fully address the poor risk assessment or inadequate datix & 72 hr reports.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 activate the ward emergency bell
Wider context from the report “4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include;
a. A ward emergency bell was not sounded ,
b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles.
c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination,
d. Duty doctors were not called promptly,
e. Oxygen administration was delayed,
f. An on-site defibrillator was not used by staff
g. Staff could or would not provide a clear and relevant history to paramedics.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of serious incident investigation to address risk-assessment and reporting deficiencies
Wider context from the report “6. Governance process failings.
a. A datix incident report created on the evening of 10ᵗʰ April 2021 by a senior nurse and Modern Matron contained misleading information that suggested that emergency response policies were followed when in fact they were not.
b. The Datix failed to mention that observations had been suspended by the shift coordinator, a fact that was understood at that time. This obvious and significant piece of information that should have been escalated through the Trust governance team for action.
c. The Trust 72 hour report was written by the Modern Matron and was signed-off by an integrated care director on 15th April 2021. This document also failed to identify or escalate the significant issue of the suspension of observation at 16.00 on 10th April 2021.
d. The Trust SI report was not prepared to fully address the poor risk assessment or inadequate datix & 72 hr reports.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 carry out prescribed patient observations
Wider context from the report “3. A failure to ensure that a treatment plan was followed - observations between 16.00 and 17.00 on the day of Mr Charles’ death were suspended by the ward shift co-ordinator . The decision meant all patients subject to general observation on the ward were ignored .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 accurate and reliable observation records
Wider context from the report “5. The credibility of evidence provided by Trust staff.
a. Two Trust witnesses declined to answer questions put to them regarding whether their observation records were truthful.
b. Observation records appeared to have been created utilising a “cut and paste” function .
c. Records often inaccurately recorded the prescribed frequency of observation.
d. Factually inaccurate entries were made in the record following Mr Charles’ death. On 11ᵗʰ April 2021 an entry stated that Mr Charles was, “awake in his bedroom sitting on his bed (sic)” at 07.21. On 12ᵗʰ April two entries made at 9.48 and 11.40 recorded that Mr Charles’ was alive and well. Senior Trust witnesses characterised these entries as dishonest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to use the anti-barricade key to access a barricaded room
Wider context from the report “4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include;
a. A ward emergency bell was not sounded,
b. An anti-barricade key was not used to open Mr Charles’ door , instead the door was forced open causing a risk of harm to Mr Charles .
c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination,
d. Duty doctors were not called promptly,
e. Oxygen administration was delayed,
f. An on-site defibrillator was not used by staff
g. Staff could or would not provide a clear and relevant history to paramedics.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to align observation frequency decisions with policy guidance
Wider context from the report “2. A decision to reduce observation frequency made by the MDT on 6/4/21 was not supported by the Trust Policy guidance which indicated that enhanced observations were appropriate .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 a ligature cutter for prompt emergency use
Wider context from the report “4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include;
a. A ward emergency bell was not sounded,
b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles.
c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination ,
d. Duty doctors were not called promptly,
e. Oxygen administration was delayed,
f. An on-site defibrillator was not used by staff
g. Staff could or would not provide a clear and relevant history to paramedics.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide paramedics with a clear and relevant patient history
Wider context from the report “4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include;
a. A ward emergency bell was not sounded,
b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles.
c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination,
d. Duty doctors were not called promptly,
e. Oxygen administration was delayed,
f. An on-site defibrillator was not used by staff
g. Staff could or would not provide a clear and relevant history to paramedics .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in administering oxygen during emergencies
Wider context from the report “4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include;
a. A ward emergency bell was not sounded,
b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles.
c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination,
d. Duty doctors were not called promptly,
e. Oxygen administration was delayed ,
f. An on-site defibrillator was not used by staff
g. Staff could or would not provide a clear and relevant history to paramedics.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in calling duty doctors during emergencies
Wider context from the report “4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include;
a. A ward emergency bell was not sounded,
b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles.
c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination,
d. Duty doctors were not called promptly ,
e. Oxygen administration was delayed,
f. An on-site defibrillator was not used by staff
g. Staff could or would not provide a clear and relevant history to paramedics.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and escalate observation suspension in the 72-hour report
Wider context from the report “6. Governance process failings.
a. A datix incident report created on the evening of 10ᵗʰ April 2021 by a senior nurse and Modern Matron contained misleading information that suggested that emergency response policies were followed when in fact they were not.
b. The Datix failed to mention that observations had been suspended by the shift coordinator, a fact that was understood at that time. This obvious and significant piece of information that should have been escalated through the Trust governance team for action.
c. The Trust 72 hour report was written by the Modern Matron and was signed-off by an integrated care director on 15th April 2021. This document also failed to identify or escalate the significant issue of the suspension of observation at 16.00 on 10th April 2021.
d. The Trust SI report was not prepared to fully address the poor risk assessment or inadequate datix & 72 hr reports.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to use the on-site defibrillator during an emergency
Wider context from the report “4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include;
a. A ward emergency bell was not sounded,
b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles.
c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination,
d. Duty doctors were not called promptly,
e. Oxygen administration was delayed,
f. An on-site defibrillator was not used by staff
g. Staff could or would not provide a clear and relevant history to paramedics.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Concerns about care provision and coordination are mainly for the NHS Trust to address.
Verbatim wording from the response “Your report raises concerns over the provision and coordination of care that Winbourne received at North East London NHS Foundation Trust, which are mainly for the Trust to address. I understand that the Trust has already carefully considered the matters of concern in your report and has provided you with a comprehensive response as well as a copy of its action plan setting out the actions to be taken to improve care quality and patient safety.” Source location Response from Department of Health and Social Care
Open published response
24 Apr 2023 Christopher Evans · Prevention of Future Deaths report Avon
View report summary
Concerns raised 3 Lack of a requirement to assess and manage scalding risk in HMOs accommodating vulnerable persons View source Lack of a requirement for thermostatic control valves on hot water taps in supported accommodation View source Lack of regulatory oversight and inspection of HMOs accommodating vulnerable persons 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
Christopher Evans · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Evans, who was vulnerable and had physical health problems, was found unresponsive and almost completely submerged in a bath of very hot water on 28 September 2020 and was pronounced dead at the scene. The report identified concerns that his supported accommodation was not subject to CQC or HSE oversight and that the regulatory framework did not require assessment or management of scalding risks or provision of engineering controls for vulnerable residents.
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 requirement to assess and manage scalding risk in HMOs accommodating vulnerable persons
Wider context from the report “(1) Mr. Evans resided in supported accommodation which was appropriately licensed as an HMO. The provision and maintenance of services, including electricity, gas and water was the responsibility of Supported Independence Limited. However, the HMO licence did not require there be thermostatic control valves fitted to the hot water taps in the Deceased's flat.
(2) Since the Deceased resided in his own accommodation and was not provided with a regulated activity, the accommodation was not regulated nor subject to inspection by the CQC.
(3) Similarly the HSE had no authority to inspect premises under the Health and Safety at Work Act 1974 as the Deceased resided in his own home.
(4) If the Deceased, who was vulnerable, had resided in health and social care premises then there would have been a requirement to assess the risk of scalding and burning in the context of his vulnerability.
(5) Engineering controls could then have been provided to minimise the risk of scalding particularly where there is whole body immersion.
(6) In accommodating vulnerable persons in such an HMO there appears to be a deficiency in the regulatory framework in that there is no requirement to assess and manage the risk of scalding and no overview by any regulatory body.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a requirement for thermostatic control valves on hot water taps in supported accommodation
Wider context from the report “(1) Mr. Evans resided in supported accommodation which was appropriately licensed as an HMO. The provision and maintenance of services, including electricity, gas and water was the responsibility of Supported Independence Limited. However, the HMO licence did not require there be thermostatic control valves fitted to the hot water taps in the Deceased's flat .
(2) Since the Deceased resided in his own accommodation and was not provided with a regulated activity, the accommodation was not regulated nor subject to inspection by the CQC.
(3) Similarly the HSE had no authority to inspect premises under the Health and Safety at Work Act 1974 as the Deceased resided in his own home.
(4) If the Deceased, who was vulnerable, had resided in health and social care premises then there would have been a requirement to assess the risk of scalding and burning in the context of his vulnerability.
(5) Engineering controls could then have been provided to minimise the risk of scalding particularly where there is whole body immersion.
(6) In accommodating vulnerable persons in such an HMO there appears to be a deficiency in the regulatory framework in that there is no requirement to assess and manage the risk of scalding and no overview by any regulatory body.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory oversight and inspection of HMOs accommodating vulnerable persons
Wider context from the report “(1) Mr. Evans resided in supported accommodation which was appropriately licensed as an HMO. The provision and maintenance of services, including electricity, gas and water was the responsibility of Supported Independence Limited. However, the HMO licence did not require there be thermostatic control valves fitted to the hot water taps in the Deceased's flat.
(2) Since the Deceased resided in his own accommodation and was not provided with a regulated activity, the accommodation was not regulated nor subject to inspection by the CQC .
(3) Similarly the HSE had no authority to inspect premises under the Health and Safety at Work Act 1974 as the Deceased resided in his own home.
(4) If the Deceased, who was vulnerable, had resided in health and social care premises then there would have been a requirement to assess the risk of scalding and burning in the context of his vulnerability.
(5) Engineering controls could then have been provided to minimise the risk of scalding particularly where there is whole body immersion.
(6) In accommodating vulnerable persons in such an HMO there appears to be a deficiency in the regulatory framework in that there is no requirement to assess and manage the risk of scalding and no overview by any regulatory body .
” Open source report
24 Apr 2023 Samuel Thomas Howes · Prevention of Future Deaths report South London
View report summary
Concerns raised 6 Inadequate mental health and social care responses to alcohol dependency View source Lack of a complex service providing adolescents with treatment for both substance misuse and mental health issues View source Inadequate provision of care to adolescents with mental health vulnerabilities and substance use difficulties View source Failure of Child & Adolescent Mental Health Service teams to work together effectively View source Failure to provide a rehabilitative placement View source Delays in Adult Complex Additions Service responses to referrals View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Samuel Thomas Howes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Samuel Thomas Howes died from fatal injuries after jumping in front of a train on 2 September 2020. The inquest found that his ongoing mental health issues, drug use and alcohol dependency probably contributed to his death. Substantive concerns included inadequate mental health and social care responses, failures to share risk information between agencies, inadequate custody safeguarding and failures in the missing-person investigation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate mental health and social care responses to alcohol dependency
Wider context from the report “(4) The inadequate response of mental health and social care services in relation to Samuel’s dependency on alcohol and the provision of a rehabilitative placement.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 complex service providing adolescents with treatment for both substance misuse and mental health issues
Wider context from the report “(3) The lack of a complex service providing, to adolescents, treatment for both substance misuse and mental health issues models, in terms of willingness to engage, being problematic for some young people.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate provision of care to adolescents with mental health vulnerabilities and substance use difficulties
Wider context from the report “(2) The delayed response of the Adult Complex Additions Service to referral and issues related to provision of care to adolescents presenting with mental health vulnerabilities and substance use difficulties .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Child & Adolescent Mental Health Service teams to work together effectively
Wider context from the report “(1) Samuel’s case should be a stimulus for some level of Child & Adolescent Mental Health Service reflection on how different Child and Adolescent Mental Health Service teams are organised and work together.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a rehabilitative placement
Wider context from the report “(4) The inadequate response of mental health and social care services in relation to Samuel’s dependency on alcohol and the provision of a rehabilitative placement .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Adult Complex Additions Service responses to referrals
Wider context from the report “(2) The delayed response of the Adult Complex Additions Service to referral and issues related to provision of care to adolescents presenting with mental health vulnerabilities and substance use difficulties.
” 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 Develop a joint action plan to improve access to mental health services and links with drug and alcohol treatment services.
Verbatim wording from the response “This is why the Department and NHS England are working together on a joint action plan to improve the mental health treatment offer for people who use drugs and alcohol. This includes improving access to mental health services for people using drugs and alcohol as people are currently too often excluded from, and/or fall between the thresholds of, services. It will also promote better links between mental health services and drug and alcohol treatment services to ensure people receive joined-up care. The first phase of the programme targets adult mental health services, and a second plan for children and young people will follow.” 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 a second joint plan addressing co-occurring mental health and substance misuse needs among children and young people.
Verbatim wording from the response “This is why the Department and NHS England are working together on a joint action plan to improve the mental health treatment offer for people who use drugs and alcohol. This includes improving access to mental health services for people using drugs and alcohol as people are currently too often excluded from, and/or fall between the thresholds of, services. It will also promote better links between mental health services and drug and alcohol treatment services to ensure people receive joined-up care. The first phase of the programme targets adult mental health services, and a second plan for children and young people will follow.” 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 guidance on commissioning and providing joined-up services for people with co-occurring mental health and substance misuse problems.
Verbatim wording from the response “In addition, the Office for Health Improvement and Disparities (formerly Public Health England) has published guidance to support the commissioning and provision of joined up services for people with co-occurring mental health and substance misuse problems. The guidance sets out the principles which should underpin the way substance misuse and mental health services work together, including that each person should have access to a care co-ordinator to help ensure all their needs are addressed. This is available at: Better care for people with co-occurring mental health, and alcohol and drug use conditions (publishing.service.gov.uk)” 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 an additional £532 million in drug and alcohol treatment and recovery services, including children’s treatment capacity and quality.
Verbatim wording from the response “In addition, the Government has committed to investing an additional £532 million to improve drug and alcohol treatment and recovery services from 2022/23 to 2024/25, building on an £80 million investment in 2021/22. This includes improving the capacity and quality of children and young people’s treatment, with an ambition to get an extra 5,000 children and young people in treatment by 2024/25.” 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 is mainly responsible for addressing the concerns about care provision for children and young people with complex needs.
Verbatim wording from the response “In preparing this response, Departmental officials have made enquiries with NHS England as the matters of concern you have raised are mainly for NHS England to address. I understand that NHS England has already provided you with a comprehensive response, setting out what progress is being made to improve children and young people’s mental health services, and how the Framework for Integrated Care (Community) Framework is helping young people with the most complex needs.” Source location Response from Department of Health and Social Care
Open published response
20 Apr 2023 Joseph Willy Maunick · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 3 Failure to promptly transfer patients to an available ward bed or appropriate alternative place View source Insufficient hospital resources and staffing to provide required care and supervision View source Insufficient provision of suitable care, including residential care placements View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joseph Willy Maunick · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joseph Willy Maunick died on 15 March 2022 from a severe head injury sustained in a fall in the Emergency Department of West Suffolk Hospital, where he had been admitted as a social admission while his wife underwent emergency surgery. The report identified concerns about a national shortage of suitable care, and severe hospital pressures including insufficient staffing and resources, which prevented the constant supervision he needed and delayed transfer to a more appropriate environment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly transfer patients to an available ward bed or appropriate alternative place
Wider context from the report “2) The severe pressures on the hospital, including the Emergency Department, were such that they were experiencing scarcity of resource relative to demand and a severe deficiency of staff. In these circumstances, it was both not possible to provide the care and supervision that Will needed in the Emergency Department, and the scarcity of resource contributed to Will not being transferred sooner to a ward or other more appropriate environment , where Will could receive the constant supervision that would probably have prevented the fall that led to his death. The evidence was that the scarcity of resource experienced was a challenge on the national level, rather than just a particular local issue. If hospitals, including Emergency Departments, do not receive sufficient resource, then circumstances creating a risk of future deaths, due to an inability to provide the required care and / or prompt transfer to an available ward bed or appropriate alternative place , will occur or continue to exist in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 hospital resources and staffing to provide required care and supervision
Wider context from the report “2) The severe pressures on the hospital, including the Emergency Department, were such that they were experiencing scarcity of resource relative to demand and a severe deficiency of staff . In these circumstances, it was both not possible to provide the care and supervision that Will needed in the Emergency Department , and the scarcity of resource contributed to Will not being transferred sooner to a ward or other more appropriate environment, where Will could receive the constant supervision that would probably have prevented the fall that led to his death. The evidence was that the scarcity of resource experienced was a challenge on the national level, rather than just a particular local issue. If hospitals, including Emergency Departments, do not receive sufficient resource , then circumstances creating a risk of future deaths, due to an inability to provide the required care and / or prompt transfer to an available ward bed or appropriate alternative place, will occur or continue to exist in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient provision of suitable care, including residential care placements
Wider context from the report “1) A national care shortage contributed to a situation where a gentleman who was not experiencing a medical emergency, but who required constant supervision for his own safety in view of his cognitive impairment and very high falls risk, could not be cared for anywhere other than in a hospital Emergency Department. If there is not sufficient provision of care, including residential care placements , such that those in similar need do not receive suitable care , then circumstances creating a risk of future deaths will occur or continue to exist in the future, when they are placed in an environment that is not realistically able to provide the constant supervision needed, as occurred in this case.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £16 million to partners to support improved local authority commissioning of adult social care.
Verbatim wording from the response “Last year, £16m was provided to partners to make support available including a focus on how local authorities commission the right kind of care to meet the needs of everyone who draws on care and support. Secretary of State also require adult social care providers to share their data with us to allow for more awareness and insight on what is happening locally and nationally.” Source location 2023-0128 - 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 Local authorities are responsible for shaping care markets to ensure sufficient, diverse, sustainable adult social care provision, including residential placements.
Verbatim wording from the response “With regard to your concern about a potential national care shortage and insufficient provision of care, including residential care placements, under the Care Act, local authorities are tasked with the duty to shape their care market to ensure a diverse range of high quality, sustainable, person-centred care and support services are provided.” Source location 2023-0128 - Response from Department of Health and Social Care
Open published response
18 Apr 2023 Patrick Soames · Prevention of Future Deaths report South London
View report summary
Concerns raised 4 Failure to share or provide access to critical self-harm risk information for directly involved NHS Trusts View source Lack of a single effective global focus for consolidating and retrieving cross-agency risk information View source Unavailability of GP-held clinical history to accident and emergency departments outside surgery hours or across geographic areas View source Lack of a national risk-flagging system for previous self-harm attendances View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Patrick Soames · 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
Patrick Soames died by suicide on 21 June 2021 after a final month involving repeated serious self-harm, including cutting, medication overdose and excessive alcohol misuse, with multiple hospital attendances. The principal concerns were that information about his risk was fragmented across NHS Trusts, police forces, local authorities and geographical areas, with no effective system to consolidate or flag his recent self-harm history nationally.
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 share or provide access to critical self-harm risk information for directly involved NHS Trusts
Wider context from the report “1. 5 NHS Trusts and 3 police forces in different geographic areas had contact with Patrick in the final month of his life and each thereby gained some information about the risk to him. However, that information was by reason of the agencies falling into different geographic areas. There was no single effective global focus for the information being acquired piecemeal about Patrick’s pattern of serious self-harming behaviour. The various agencies were significantly impeded in forming a single clear picture of Patrick’s pattern of behaviour (which was particularly necessary in circumstances where he was not engaging and therefore not assisting in providing a complete history himself).
2. GPs act as a repository for information about contact with other clinical agencies (such as attendances at accident and emergency departments) and therefore serve as a point of contact for information about past history. However, I heard evidence at inquest from accident and emergency consultants that it is either not possible to access information held by a GP outside of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the accident and emergency department. Several of Patrick’s attendances at accident and emergency departments were out of GP surgery hours.
3. I was informed at inquest that one local authority (in whose area Patrick resided) had been made aware by police of the risk to Patrick following one of his self-harm incidents (in respect of a particularly important piece of information) and had relayed that information to a 6th NHS Trust (not one of the 5 from which I heard evidence at inquest) but Patrick did not reside in that Trust area. Those Trusts which did have direct contact with Patrick were never made aware of that piece of information nor had any means of accessing it.
4. I heard evidence that there is no national ‘risk flagging’ system: for example, when a person attends an accident and emergency department having self-harmed, the fact of a previous self-harm attendance at a different accident and emergency department is not systematically flagged up.
5. In summary, there was no single effective global focus consolidating the information which was flowing into the various agencies about Patrick; no global focus to which those agencies could in turn refer in emergency to obtain the totality of information about Patrick’s recent pattern of behaviour; no national ‘risk flagging’ system to alert those agencies to his significant recent history.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 single effective global focus for consolidating and retrieving cross-agency risk information
Wider context from the report “1. 5 NHS Trusts and 3 police forces in different geographic areas had contact with Patrick in the final month of his life and each thereby gained some information about the risk to him. However, that information was by reason of the agencies falling into different geographic areas. There was no single effective global focus for the information being acquired piecemeal about Patrick’s pattern of serious self-harming behaviour. The various agencies were significantly impeded in forming a single clear picture of Patrick’s pattern of behaviour (which was particularly necessary in circumstances where he was not engaging and therefore not assisting in providing a complete history himself).
2. GPs act as a repository for information about contact with other clinical agencies (such as attendances at accident and emergency departments) and therefore serve as a point of contact for information about past history. However, I heard evidence at inquest from accident and emergency consultants that it is either not possible to access information held by a GP outside of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the accident and emergency department. Several of Patrick’s attendances at accident and emergency departments were out of GP surgery hours.
3. I was informed at inquest that one local authority (in whose area Patrick resided) had been made aware by police of the risk to Patrick following one of his self-harm incidents (in respect of a particularly important piece of information) and had relayed that information to a 6th NHS Trust (not one of the 5 from which I heard evidence at inquest) but Patrick did not reside in that Trust area. Those Trusts which did have direct contact with Patrick were never made aware of that piece of information nor had any means of accessing it.
4. I heard evidence that there is no national ‘risk flagging’ system: for example, when a person attends an accident and emergency department having self-harmed, the fact of a previous self-harm attendance at a different accident and emergency department is not systematically flagged up.
5. In summary, there was no single effective global focus consolidating the information which was flowing into the various agencies about Patrick ; no global focus to which those agencies could in turn refer in emergency to obtain the totality of information about Patrick’s recent pattern of behaviour ; no national ‘risk flagging’ system to alert those agencies to his significant recent history.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 GP-held clinical history to accident and emergency departments outside surgery hours or across geographic areas
Wider context from the report “1. 5 NHS Trusts and 3 police forces in different geographic areas had contact with Patrick in the final month of his life and each thereby gained some information about the risk to him. However, that information was by reason of the agencies falling into different geographic areas. There was no single effective global focus for the information being acquired piecemeal about Patrick’s pattern of serious self-harming behaviour. The various agencies were significantly impeded in forming a single clear picture of Patrick’s pattern of behaviour (which was particularly necessary in circumstances where he was not engaging and therefore not assisting in providing a complete history himself).
2. GPs act as a repository for information about contact with other clinical agencies (such as attendances at accident and emergency departments) and therefore serve as a point of contact for information about past history. However, I heard evidence at inquest from accident and emergency consultants that it is either not possible to access information held by a GP outside of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the accident and emergency department . Several of Patrick’s attendances at accident and emergency departments were out of GP surgery hours.
3. I was informed at inquest that one local authority (in whose area Patrick resided) had been made aware by police of the risk to Patrick following one of his self-harm incidents (in respect of a particularly important piece of information) and had relayed that information to a 6th NHS Trust (not one of the 5 from which I heard evidence at inquest) but Patrick did not reside in that Trust area. Those Trusts which did have direct contact with Patrick were never made aware of that piece of information nor had any means of accessing it.
4. I heard evidence that there is no national ‘risk flagging’ system: for example, when a person attends an accident and emergency department having self-harmed, the fact of a previous self-harm attendance at a different accident and emergency department is not systematically flagged up.
5. In summary, there was no single effective global focus consolidating the information which was flowing into the various agencies about Patrick; no global focus to which those agencies could in turn refer in emergency to obtain the totality of information about Patrick’s recent pattern of behaviour; no national ‘risk flagging’ system to alert those agencies to his significant recent history.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 national risk-flagging system for previous self-harm attendances
Wider context from the report “1. 5 NHS Trusts and 3 police forces in different geographic areas had contact with Patrick in the final month of his life and each thereby gained some information about the risk to him. However, that information was by reason of the agencies falling into different geographic areas. There was no single effective global focus for the information being acquired piecemeal about Patrick’s pattern of serious self-harming behaviour. The various agencies were significantly impeded in forming a single clear picture of Patrick’s pattern of behaviour (which was particularly necessary in circumstances where he was not engaging and therefore not assisting in providing a complete history himself).
2. GPs act as a repository for information about contact with other clinical agencies (such as attendances at accident and emergency departments) and therefore serve as a point of contact for information about past history. However, I heard evidence at inquest from accident and emergency consultants that it is either not possible to access information held by a GP outside of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the accident and emergency department. Several of Patrick’s attendances at accident and emergency departments were out of GP surgery hours.
3. I was informed at inquest that one local authority (in whose area Patrick resided) had been made aware by police of the risk to Patrick following one of his self-harm incidents (in respect of a particularly important piece of information) and had relayed that information to a 6th NHS Trust (not one of the 5 from which I heard evidence at inquest) but Patrick did not reside in that Trust area. Those Trusts which did have direct contact with Patrick were never made aware of that piece of information nor had any means of accessing it.
4. I heard evidence that there is no national ‘risk flagging’ system : for example, when a person attends an accident and emergency department having self-harmed, the fact of a previous self-harm attendance at a different accident and emergency department is not systematically flagged up .
5. In summary, there was no single effective global focus consolidating the information which was flowing into the various agencies about Patrick; no global focus to which those agencies could in turn refer in emergency to obtain the totality of information about Patrick’s recent pattern of behaviour; no national ‘risk flagging’ system to alert those agencies to his significant recent history .
” Open source report
18 Apr 2023 John Edward Stiff · Prevention of Future Deaths report East London
View report summary
Concerns raised 1 Insufficient orthogeriatric provision for elderly orthopaedic trauma patients with comorbidities View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
John Edward Stiff · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Edward Stiff was admitted to Queen's Hospital after a believed unwitnessed fall and was diagnosed with an undisplaced pelvic fracture. His condition declined, including reduced appetite and a chest infection, and he died at the hospital on 16 November 2022. The report raised concerns that patients with hip and pelvic fractures and age-related co-morbidities would be better cared for by orthogeriatricians, and that limited access to such care could contribute to untimely 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 Insufficient orthogeriatric provision for elderly orthopaedic trauma patients with comorbidities
Wider context from the report “The Inquest heard evidence from an orthopaedic surgeon that patients such as Mr Stiff, who suffer hip and pelvic fractures and who have a number of additional age-related co-morbidities, would be best cared for by ortho-geriatricians . The inquest heard that this matter has been raised by the orthopaedic team on multiple occasions, but the orthogeriatric provision has not been increased .
The Inquest also heard that the lack of orthogeriatric provision is a national issue of concern within the NHS .
Orthopaedic trauma in elderly patients often exacerbates underlying medical conditions . Orthogeriatric trained staff would be better trained to recognise and treat medical co-morbidities . It is therefore considered that improved access to orthogeriatric care for this patient cohort could prevent future untimely deaths.
” 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 Individual NHS Trusts are responsible for creating orthogeriatric care pathways based on local patients and workforce skills.
Verbatim wording from the response “Orthogeriatric care is a medical-surgical model which brings together multidisciplinary health professionals from trauma, orthopaedics and geriatric medicine to treat the fracture and frailty issues affecting people with hip fractures. I understand that Orthogeriatric provision varies across the NHS. Each individual Trust will create their own care pathways, having regard to both their patients and the skills of their workforce.” Source location Response from Department of Health and Social Care
Open published response
6 Apr 2023 Alexandra Briess · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 9 Barriers to information sharing about deceased anaphylaxis patients View source Failure to mandate referral of fatal anaphylaxis cases View source Inadequate immediate investigation of suspected anaphylaxis deaths View source Lack of a national reporting and fatality-register system for anaphylaxis View source Lack of named accountability for allergy services and provision View source Lack of a clear UKFAR referral requirement after unsuccessful resuscitation View source Failure to robustly capture and record fatal and near-fatal anaphylaxis cases View source Insufficient funding for anaphylaxis data gathering and research View source Lack of national leadership for anaphylaxis work View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alexandra Briess · 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
Alexandra Briess underwent tonsillectomy, later required surgery for post-operative bleeding, and suffered sudden deterioration and cardiac arrest during anaesthesia on 30 May 2021. She died on 31 May 2021, with the most likely cause identified as an anaphylactic reaction to Rocuronium; there were no concerns about her clinical management. The principal concerns were the lack of national leadership and funding for anaphylaxis work, mandatory reporting of fatal anaphylaxis, and improved national data gathering, research and information sharing.
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 Barriers to information sharing about deceased anaphylaxis patients
Wider context from the report “5. Information sharing amongst the organisations referred to in this report should be straightforward . Confidentiality constraints are important, but not the same in the case of a deceased person as they are for a living person . I believe that a confidential advisory group has already started to consider this matter.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 mandate referral of fatal anaphylaxis cases
Wider context from the report “It seems clear to all coroners in these cases, and those involved in this area of medical expertise, that the only way to improve understanding and prevent or reduce future deaths is to gather information nationally and fund appropriate research.
Appropriate organisations already exist, and there is a lot of goodwill towards improving understanding in this area. It does however require national leadership and “joining up” of these organisations.
1. I have tried to make my list of issues clear and succinct. Paragraph 2 below sets out the crux of this ongoing risk.
2. There is significant goodwill and desire to improve amongst numerous organisations involved in anaphylaxis work. What is lacking is national leadership and funding. In my view, consideration should be given to creating a leadership role and responsibility within NHS England to coordinate a national approach.
3. As considered by other coroners before me, it should be mandatory to refer fatal anaphylaxis cases . UKFAR has indicated that they would be prepared to take on the role of receiving these reports (to avoid duplication for reporting clinicians), with the responsibility to forward the relevant information to other organisations such as the MHRA, where appropriate. Whilst my focus is on fatal anaphylaxis, inclusion of non-fatal cases would be a matter for the lead role to consider.
4. Gathering data and using this to research and reduce the risk of future deaths requires funding, and this should be reviewed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 immediate investigation of suspected anaphylaxis deaths
Wider context from the report ““Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis , that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths , but that to achieve this, changes are required .
In relation to the Food Standards Agency, the UK Health Security Agency, and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxes, and specifically, fatal and near-fatal anaphylaxis…
• Such a system could involve, mandatory reporting of anaphylaxis presenting to hospital analogous to the current system for notifiable diseases… by registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the State of Victoria in Australia, and allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate public health risk.”
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a national reporting and fatality-register system for anaphylaxis
Wider context from the report ““In my opinion action should be taken to consider establishing a national reporting system which includes timely reporting to local authority and FSA and maintenance of a register of fatalities and their investigations , and consideration be given to investigating the feasibility of wider access to AAI’s. I believe that the organizations would wish to learn of the circumstances of this death and are in a position to facilitate a collaborative process to mitigate or prevent future deaths.”
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of named accountability for allergy services and provision
Wider context from the report ““The issues within this Prevention of Future Deaths report are predominantly national issues, but I heard at inquest that there is no person with named accountability for allergy services and allergy provision at NHS England, or the Department of Health as a whole .”
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear UKFAR referral requirement after unsuccessful resuscitation
Wider context from the report “6. Consideration of including contact details for the UKFAR in algorithms used by doctors attempting to resuscitate patients – so that there is a clear requirement for referral to UKFAR in the event of an unsuccessful resuscitation . This is currently being considered by the Resuscitation Council UK.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 robustly capture and record fatal and near-fatal anaphylaxis cases
Wider context from the report ““Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this, changes are required.
In relation to the Food Standards Agency, the UK Health Security Agency, and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxes, and specifically, fatal and near-fatal anaphylaxis …
• Such a system could involve, mandatory reporting of anaphylaxis presenting to hospital analogous to the current system for notifiable diseases… by registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the State of Victoria in Australia, and allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate public health risk.”
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient funding for anaphylaxis data gathering and research
Wider context from the report “It seems clear to all coroners in these cases, and those involved in this area of medical expertise, that the only way to improve understanding and prevent or reduce future deaths is to gather information nationally and fund appropriate research.
Appropriate organisations already exist, and there is a lot of goodwill towards improving understanding in this area. It does however require national leadership and “joining up” of these organisations.
1. I have tried to make my list of issues clear and succinct. Paragraph 2 below sets out the crux of this ongoing risk.
2. There is significant goodwill and desire to improve amongst numerous organisations involved in anaphylaxis work. What is lacking is national leadership and funding. In my view, consideration should be given to creating a leadership role and responsibility within NHS England to coordinate a national approach.
3. As considered by other coroners before me, it should be mandatory to refer fatal anaphylaxis cases. UKFAR has indicated that they would be prepared to take on the role of receiving these reports (to avoid duplication for reporting clinicians), with the responsibility to forward the relevant information to other organisations such as the MHRA, where appropriate. Whilst my focus is on fatal anaphylaxis, inclusion of non-fatal cases would be a matter for the lead role to consider.
4. Gathering data and using this to research and reduce the risk of future deaths requires funding , and this should be reviewed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national leadership for anaphylaxis work
Wider context from the report “It seems clear to all coroners in these cases, and those involved in this area of medical expertise, that the only way to improve understanding and prevent or reduce future deaths is to gather information nationally and fund appropriate research.
Appropriate organisations already exist, and there is a lot of goodwill towards improving understanding in this area. It does however require national leadership and “joining up” of these organisations.
1. I have tried to make my list of issues clear and succinct. Paragraph 2 below sets out the crux of this ongoing risk.
2. There is significant goodwill and desire to improve amongst numerous organisations involved in anaphylaxis work. What is lacking is national leadership and funding . In my view, consideration should be given to creating a leadership role and responsibility within NHS England to coordinate a national approach.
3. As considered by other coroners before me, it should be mandatory to refer fatal anaphylaxis cases. UKFAR has indicated that they would be prepared to take on the role of receiving these reports (to avoid duplication for reporting clinicians), with the responsibility to forward the relevant information to other organisations such as the MHRA, where appropriate. Whilst my focus is on fatal anaphylaxis, inclusion of non-fatal cases would be a matter for the lead role to consider.
4. Gathering data and using this to research and reduce the risk of future deaths requires funding, and this should be reviewed.
” 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 Establish and jointly chair an Expert Advisory Group for Allergy to identify priority policy areas and advise on improving outcomes.
Verbatim wording from the response “An Expert Advisory Group for Allergy (EAGA) has recently been established, which brings together key stakeholders with the aim improving the quality-of-life of people with allergies. Chaired jointly by the Department of Health and Social Care and the National Allergy Strategy Group, the EAGA identifies priority areas for the Department, NHSE and other government department and agencies relating to allergy that require policy change or development and advises on how to best achieve improved 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 NHS England is responsible for national clinical policy and strategy for allergy services in England, rather than the Department.
Verbatim wording from the response “In relation to national accountability for allergy services, following the reforms initiated by the Health and Social Care Act 2012, NHS England (NHSE) is responsible for clinical policy and strategy in the NHS in England (including for allergies) and is held to account through the annual NHS mandate.” 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 Existing NHS England allergy advisory structures and its process for reviewing National Clinical Director posts address national leadership without requiring an allergy director now.
Verbatim wording from the response “While there is indeed currently no National Clinical Director (or ‘Tsar’) for allergy in England, NHSE has a clinical reference group (CRG) for Specialised Immunology and Allergy Services that provides advice on specialised services and commissioning policies and quality standards. The CRG is chaired by NHSE’s National Specialty Advisor (NSA) for clinical immunology and allergy, Dr Claire Bethune, a clinical immunologist, and allergy clinical immunology expert clinicians are among the membership.” Source location Response from Department of Health and Social Care
Open published response
3 Apr 2023 Name not published · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 1 Delays in timely assessment of young people 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
Name not published · 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
████████ died at home on 24 September 2022 after becoming unresponsive following a hanging incident; he could not be revived despite resuscitation efforts, and the inquest recorded misadventure. At the time of his death, he was awaiting assessment for autism after a wait of around three years. The report raised concern that delays in assessment and insufficient support placed him and other children at risk, and that earlier diagnosis and support might have avoided his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in timely assessment of young people
Wider context from the report “• With finite resources, it is acknowledged that it may not be possible for all young people to be assessed in as timely a manner as required, but there must surely come a point whereby, notwithstanding those finite resources, the wait for assessment is taking too long .
• The wait for assessment placed ████████ at risk , and other children will be similarly at risk in the absence of a timely assessment .
• It is possible that he had been diagnosed earlier, and with enough time for the relevant professionals to have been able to carry out some meaningful work with him, and had his extremely supportive Parents been given more support, ████████ death may have been avoided.
” Open source report
31 Mar 2023 Veronica Jenkins · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Lack of available staff to provide required operational hours View source Delays in hospital handovers across the region View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Veronica Jenkins · 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
Veronica Jenkins, a 72-year-old woman with metastatic bowel cancer, developed sudden chest pain on 10 May 2022 and died in hospital on 11 May 2022 after suffering two cardiac arrests. The report identified a delayed ambulance response caused by a deficit in operational hours, with concerns that staff shortages and hospital handover delays could recur and compromise patient safety.
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 staff to provide required operational hours
Wider context from the report “There is a risk of a future reoccurrence of the situation which arose on 10 May 2022, namely a deficit in operational hours provided by SECAMBS leading to delayed response times compromising patient safety. This risk is due firstly to a lack of available staff to provide the required operational hours and secondly to handover delays at hospitals across the region. The first issue is addressed to the Chief Executive of SECAMBS and the second issue is addressed to the Secretary of State for Health and Social 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 Delays in hospital handovers across the region
Wider context from the report “There is a risk of a future reoccurrence of the situation which arose on 10 May 2022, namely a deficit in operational hours provided by SECAMBS leading to delayed response times compromising patient safety. This risk is due firstly to a lack of available staff to provide the required operational hours and secondly to handover delays at hospitals across the region . The first issue is addressed to the Chief Executive of SECAMBS and the second issue is addressed to the Secretary of State for Health and Social Care.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the NHS Long Term Workforce Plan addressing ambulance workforce recruitment, retention and future service demands.
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. In addition, the NHS Long Term Workforce Plan published in June 2023 sets out how the NHS will address existing and future workforce challenges by recruiting and retaining thousands more staff over a 15-year period and working in new ways to improve staff experience and patient care. This will help ensure we have the ambulance workforce to meet the future demands on the service, building on the 40,000 more ambulance staff that have already joined the service since 2010.” 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 £200 million of additional funding to expand ambulance capacity and improve response times, alongside new ambulances and specialist mental health vehicles.
Verbatim wording from the response “Your report also highlights pressures on SECamb’s operational capacity at the time of the incident. A primary aim of our 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 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 to improve patient flow and reduce ambulance handover delays.
Verbatim wording from the response “Regarding handover delays, a key part of the plan has been to increase hospital capacity to improve patient flow. We have achieved the ambition of delivering 5,000 more staffed, permanent beds this year compared to 2022-23 plans - backed by £1 billion of dedicated funding. Further, we also achieved our target of scaling up virtual ward beds to over 10,000 in advance of winter. These measures will improve patient flow through hospitals, reducing delays in ambulances handing over patients so they can swiftly get back on the roads.” 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 ambulance workforce capacity through sustained investment, contributing to more than 40,000 additional ambulance staff since 2010.
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. In addition, the NHS Long Term Workforce Plan published in June 2023 sets out how the NHS will address existing and future workforce challenges by recruiting and retaining thousands more staff over a 15-year period and working in new ways to improve staff experience and patient care. This will help ensure we have the ambulance workforce to meet the future demands on the service, building on the 40,000 more ambulance staff that have already joined the service since 2010.” 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 virtual ward capacity to more than 10,000 beds to improve hospital patient flow and reduce ambulance handover delays.
Verbatim wording from the response “Regarding handover delays, a key part of the plan has been to increase hospital capacity to improve patient flow. We have achieved the ambition of delivering 5,000 more staffed, permanent beds this year compared to 2022-23 plans - backed by £1 billion of dedicated funding. Further, we also achieved our target of scaling up virtual ward beds to over 10,000 in advance of winter. These measures will improve patient flow through hospitals, reducing delays in ambulances handing over patients so they can swiftly get back on the roads.” Source location Response from Department of Health and Social Care
Open published response
26 Mar 2023 Jordan Peter Clare · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Failure to ensure that the person performing the coordination function has the necessary skills and training View source Lack of provision for vulnerable adults with complex needs outside existing care and supervision frameworks View source Ad hoc arrangements operating across differing frameworks, levels and standards View source Lack of an identifiable single point of contact for vulnerable adults with complex needs View source Absence of arrangements for contact, information sharing and coordinated deployment of services, support or safeguarding View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jordan Peter Clare · 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
Jordan Peter Clare, who had complex mental health, behavioural and substance-misuse-related needs, died on 26 August 2020 after suspending himself by a ligature at his home while distressed about an unresolved dispute with a neighbour. The principal concern was the absence of a single person or agency to coordinate care, support, information-sharing and safeguarding for vulnerable adults with complex needs who do not fall within existing social care or formal mental health frameworks.
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 that the person performing the coordination function has the necessary skills and training
Wider context from the report “The Inquest heard evidence from the Head of Service for Safeguarding and Learning for Stockport Metropolitan Borough Council. She highlighted a long-standing gap in provision, which was described as extending across most if not all local authorities, for vulnerable adults who have complex needs, but who do not fall into the existing framework of social services, Care Act provision or formal mental health supervision. The effect of that gap is that there is no identifiable individual who is a single point of contact in such cases equivalent to a social worker or care co-ordinator. The result is that many vulnerable adults with complex needs have no such arrangements in place for contact, collating and sharing of information and deployment of services and assistance, support or safeguarding. Where such arrangements are in place, they are necessarily ad hoc in nature in differing frameworks, levels and standards, and can devolve by default to an individual who, whilst well-motivated, may lack the skills and training to properly perform the function , particularly when the vulnerable adult may be in crisis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 provision for vulnerable adults with complex needs outside existing care and supervision frameworks
Wider context from the report “The Inquest heard evidence from the Head of Service for Safeguarding and Learning for Stockport Metropolitan Borough Council. She highlighted a long-standing gap in provision , which was described as extending across most if not all local authorities, for vulnerable adults who have complex needs, but who do not fall into the existing framework of social services, Care Act provision or formal mental health supervision . The effect of that gap is that there is no identifiable individual who is a single point of contact in such cases equivalent to a social worker or care co-ordinator. The result is that many vulnerable adults with complex needs have no such arrangements in place for contact, collating and sharing of information and deployment of services and assistance, support or safeguarding. Where such arrangements are in place, they are necessarily ad hoc in nature in differing frameworks, levels and standards, and can devolve by default to an individual who, whilst well-motivated, may lack the skills and training to properly perform the function, particularly when the vulnerable adult may be in crisis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Ad hoc arrangements operating across differing frameworks, levels and standards
Wider context from the report “The Inquest heard evidence from the Head of Service for Safeguarding and Learning for Stockport Metropolitan Borough Council. She highlighted a long-standing gap in provision, which was described as extending across most if not all local authorities, for vulnerable adults who have complex needs, but who do not fall into the existing framework of social services, Care Act provision or formal mental health supervision. The effect of that gap is that there is no identifiable individual who is a single point of contact in such cases equivalent to a social worker or care co-ordinator. The result is that many vulnerable adults with complex needs have no such arrangements in place for contact, collating and sharing of information and deployment of services and assistance, support or safeguarding. Where such arrangements are in place, they are necessarily ad hoc in nature in differing frameworks, levels and standards , and can devolve by default to an individual who, whilst well-motivated, may lack the skills and training to properly perform the function, particularly when the vulnerable adult may be in crisis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of an identifiable single point of contact for vulnerable adults with complex needs
Wider context from the report “The Inquest heard evidence from the Head of Service for Safeguarding and Learning for Stockport Metropolitan Borough Council. She highlighted a long-standing gap in provision, which was described as extending across most if not all local authorities, for vulnerable adults who have complex needs, but who do not fall into the existing framework of social services, Care Act provision or formal mental health supervision. The effect of that gap is that there is no identifiable individual who is a single point of contact in such cases equivalent to a social worker or care co-ordinator . The result is that many vulnerable adults with complex needs have no such arrangements in place for contact, collating and sharing of information and deployment of services and assistance, support or safeguarding. Where such arrangements are in place, they are necessarily ad hoc in nature in differing frameworks, levels and standards, and can devolve by default to an individual who, whilst well-motivated, may lack the skills and training to properly perform the function, particularly when the vulnerable adult may be in crisis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 arrangements for contact, information sharing and coordinated deployment of services, support or safeguarding
Wider context from the report “The Inquest heard evidence from the Head of Service for Safeguarding and Learning for Stockport Metropolitan Borough Council. She highlighted a long-standing gap in provision, which was described as extending across most if not all local authorities, for vulnerable adults who have complex needs, but who do not fall into the existing framework of social services, Care Act provision or formal mental health supervision. The effect of that gap is that there is no identifiable individual who is a single point of contact in such cases equivalent to a social worker or care co-ordinator. The result is that many vulnerable adults with complex needs have no such arrangements in place for contact, collating and sharing of information and deployment of services and assistance, support or safeguarding . Where such arrangements are in place, they are necessarily ad hoc in nature in differing frameworks, levels and standards, and can devolve by default to an individual who, whilst well-motivated, may lack the skills and training to properly perform the function, particularly when the vulnerable adult may be in crisis.
” Open source report
23 Mar 2023 Benjamin NELSON-ROUX · Prevention of Future Deaths report North Yorkshire and York
View report summary
Concerns raised 2 Lack of residential substance misuse treatment facilities for under-18s View source Failure to search beyond the county boundary for suitable accommodation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Benjamin NELSON-ROUX · 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
Benjamin Nelson Roux, aged 16, was found deceased on 8 April 2020 after taking multiple drugs of abuse; the cause of death was unascertained. Concerns included the lack of suitable accommodation options beyond the county boundary for a homeless 16-year-old Child in Need and the lack of residential substance-misuse treatment facilities for people under 18.
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 residential substance misuse treatment facilities for under-18s
Wider context from the report “2. The lack of any residential substance misuse treatment facilities for children and young persons under the age of 18 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 search beyond the county boundary for suitable accommodation
Wider context from the report “1. The search for suitable accommodation (in this instance for a homeless 16 year old Child in Need) did not extend beyond the County boundary .
” 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 Residential substance-misuse treatment is not best practice for most young people because community-based, coordinated interventions are generally as effective.
Verbatim wording from the response “The provision of inpatient or residential substance misuse interventions for young people away from home is only appropriate in a few, complex case and there is limited demand for residential rehabilitation – which provides an adult-oriented addiction model – for children and young people.” 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 partners, led by Children’s Services, are responsible for planning suitable residential arrangements for young people with complex needs.
Verbatim wording from the response “Where inpatient or residential support is assessed as required for young people with complex needs, local partners should come together to plan the most suitable arrangement. This may involve the young person being accommodated in temporary fostering arrangements or a child and adolescent mental health inpatient unit with support provided from the local young people’s specialist substance misuse service.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 1 Lack of automatic GP-record alerts for smear-test non-responders View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rachelle Naomi Ross · 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
Rachelle Naomi Ross, aged 34, had not undergone a smear test before being diagnosed with squamous cell carcinoma in November 2020. Despite treatment, the cancer metastasised and she died at home on 20 April 2022. The report raised concerns that GP systems did not automatically flag patients who failed to attend smear tests, potentially requiring manual recording of warnings.
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 automatic GP-record alerts for smear-test non-responders
Wider context from the report “1. During the course of the inquest I heard evidence from ████████, GP Partner at the Collingwood Health Group who informed me that GP practice records do not include an alert from EMIS or System 1 IT systems to provide an automatic flag on a patient's GP medical records if they are classed as a non-responder for a smear test by the National Screening Service.
2. The alert system is only triggered after a patient attends a smear test. For a non-responder, they go back into the three or five year waiting list for a National Screening invitation for a smear test.
3. An automatic flag or alert when a patient fails to attend for a smear test as part of the National Screening Service, would mean that a GP surgery would not have to manually add a warning as an entry onto an individual’s GP records. It would standardise the approach across all GP surgeries and could increase patient safety.
” 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 CQC lacks statutory powers over clinical system providers and therefore cannot directly require improvements in this area.
Verbatim wording from the response “In our discussions with CQC, they agree that the concerns raised by the coroner have highlighted an important area. Although CQC does not have statutory powers in relation to clinical system providers they will consider engaging with them to enquire and encourage an improvement in this area.” Source location Response from Department of Health and Social Care
Open published response
14 Feb 2023 John Abrahams (Jack) · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Failure to convene the working group required to consider implementation of the IEWG recommendations View source Failure to implement Isotretinoin prescribing recommendations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John Abrahams (Jack) · 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
Jack Abrahams was 20 years old when he took his own life by self-ligature. He had previously received a six-month course of isotretinoin for acne, but the available evidence did not meet the required standard to show a causative link between the treatment and his suicide. The principal concern was that, more than a year after the Isotretinoin Expert Working Group completed its report, its recommendations had still not been implemented, and a further working group to consider implementation had yet to meet.
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 convene the working group required to consider implementation of the IEWG recommendations
Wider context from the report “The Commission for Human Medicine (CHM) established an Isotretinoin Expert Working Group (IEWG) in response to concerns about psychiatric events. The IEWG considered oral and written evidence over 2020 and 2021. The findings and recommendations of the IEWG were presented in a report to the CHM at the end of 2021 and include a recommendation which relates to prescribing for patients under the age of 18.
It is now over a year since the IEWG report was completed and the recommendations have still not been implemented. In that time there have been 45 adverse Isotretinoin events reported to the Medicines Healthcare products Regulatory Agency (MHRA) comprising of 81 psychiatric adverse events, one of which was an attempted suicide. The Court heard that a second working group is required to consider how to implement the IEWG recommendations and that this group has yet to meet .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 implement Isotretinoin prescribing recommendations
Wider context from the report “The Commission for Human Medicine (CHM) established an Isotretinoin Expert Working Group (IEWG) in response to concerns about psychiatric events. The IEWG considered oral and written evidence over 2020 and 2021. The findings and recommendations of the IEWG were presented in a report to the CHM at the end of 2021 and include a recommendation which relates to prescribing for patients under the age of 18.
It is now over a year since the IEWG report was completed and the recommendations have still not been implemented . In that time there have been 45 adverse Isotretinoin events reported to the Medicines Healthcare products Regulatory Agency (MHRA) comprising of 81 psychiatric adverse events, one of which was an attempted suicide. The Court heard that a second working group is required to consider how to implement the IEWG recommendations and that this group has yet to meet.
” Open source report
10 Feb 2023 Celia Sanderson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Lack of DGH Emergency Department protocols and staff awareness for recognising potential silver trauma cases at arrival View source Delays in Emergency Department senior clinician review due to insufficient senior medical staffing View source Delays in Emergency Department clinician review due to patient volume and insufficient staff availability View source Delays in carrying out and reporting CT scans due to insufficient suitably qualified radiology staff 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
Celia Sanderson · 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
Celia Sanderson was involved in a road traffic collision and died at Wythenshawe Hospital after developing severe injuries, neurological damage and an acute myocardial infarction while awaiting transfer to a major trauma centre. The concerns included delays in triage and clinician review, shortages of senior emergency department and radiology staff, delays in CT scanning and reporting, and insufficient recognition of potential “silver trauma” cases in district general hospitals.
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 DGH Emergency Department protocols and staff awareness for recognising potential silver trauma cases at arrival
Wider context from the report “4. The inquest heard evidence from a trauma specialist about the importance of recognising “silver trauma”. There was recognition amongst trauma specialists of the high risk of significant trauma amongst elderly patients such as Mrs Sanderson even from what could appear to be relatively minor incidents. As a consequence major trauma centres generally had developed protocols that assisted staff at triage to pick up such cases and prioritise them and set a low threshold for an early CT scan . Such protocols were not generally in force in DGH settings . The evidence was that there needed to be steps taken to increase awareness amongst DGH ED staff to pick up these potential silver trauma cases on arrival in order to expedite discussion with and transfer to a trauma centre and increase the chances of survival.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Emergency Department senior clinician review due to insufficient senior medical staffing
Wider context from the report “2. The inquest heard that amongst the challenges faced was a shortage of ED consultants and ED middle grade doctors . Mrs Sanderson’s time at the hospital included late evening and the early hours of the morning. The inquest heard that across the NHS during these hours the number of staff at these grades in an ED is significantly reduced . Historically that had been a quieter period however demands on ED meant that was no longer the case . As a consequence senior reviews of patients were further delayed . An earlier review by a senior clinician was likely to have identified her as a potential silver trauma case and ensured she was moved to a trauma centre for appropriate treatment before she began to deteriorate;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Emergency Department clinician review due to patient volume and insufficient staff availability
Wider context from the report “1. Demands on the Emergency Department due to the volume of people waiting to be seen meant that Mrs Sanderson had a long wait for a clinician review far outside the expected target time . The inquest heard evidence that delays such as hers were common throughout that period and were due to the volume of people attending and staff available to deal with them ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 carrying out and reporting CT scans due to insufficient suitably qualified radiology staff
Wider context from the report “3. Evidence given to the inquest indicated that the ability to carry out and report promptly on CT scans was essential if trauma cases were to be identified with sufficient speed to ensure a timely transfer to a trauma unit. The inquest heard that timely transfer to a trauma unit was likely to significantly improve the outcome for a trauma patient. The inquest was told that once CT scans were requested there were often delays due to a shortage of suitably qualified staff to carry them out and then to report on them . As an example of this the inquest was told that overnight 1 radiology registrar was responsible for reporting on CT scans for 3 hospitals (Wythenshawe, the MRI and RMCH) In Mrs Sanderson’s case this meant that the ED clinician had to wait for it to be carried out and then assess the CT scan without the report ;
” 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 NHSE and local integrated care bodies are responsible for addressing the concerns about treatment at Wythenshawe Hospital.
Verbatim wording from the response “Your report raises concerns about the treatment provided at Wythenshawe Hospital, Manchester University NHS Foundation Trust. I understand that NHS England (NHSE) have written to you to address these concerns, including information from Greater Manchester Integrated Care and the Integrated Care Board on the action taken locally. This includes NHS Greater Manchester’s action plan to respond to urgent and emergency care demand pressures, as well as their Major Trauma Network. This network provides care to patients who have sustained major trauma injuries; partners work collaboratively to ensure trauma is recognised and treated appropriately. Learning from the investigation into Ms Sanderson’s death has been used to improve practice across the network.” Source location Response from DHSC
Open published response
9 Feb 2023 George Frederick Kearsey · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Failure to put fluid balance charts in place View source Failure of consultant-led ward rounds to adequately review fluid monitoring View source Poor maintenance of clinical records of fluid administration View source Failure to administer IV fluids consistently 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
George Frederick Kearsey · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
George Frederick Kearsey sustained injuries in a fall at home, was admitted to hospital, developed aspiration pneumonia, and died on the evening of 8 June 2022. Concerns included inconsistent administration of IV fluids, missing fluid balance charts, poorly maintained clinical records, and inadequate review of fluid monitoring during consultant-led ward rounds.
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 put fluid balance charts in place
Wider context from the report “2. Contrary to Trust policy, fluid balance charts were not put in place to assess Mr Kearsey’s fluid intake and output .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 consultant-led ward rounds to adequately review fluid monitoring
Wider context from the report “4. Consultant-led ward rounds did not adequately review fluid monitoring .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor maintenance of clinical records of fluid administration
Wider context from the report “3. Clinical records were poorly maintained , resulting in an unclear picture of fluid administration .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 administer IV fluids consistently
Wider context from the report “1. IV fluids were not administered consistently . The longest period in which fluids were not administered was 17 hours and 45 minutes.
” Open source report
Concerns raised 1 Lack of policies and procedures preventing failure to cap patent central venous catheter lines during patient mobilisation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Richard Nigel KEW · 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
Richard Nigel KEW underwent surgery for a small bowel neuroendocrine tumour and multiple liver metastases. During mobilisation after surgery, a central venous catheter line was not secured with a bung, allowing air to enter his circulation; he deteriorated, never regained consciousness, and died on 5 September 2022. The concern was that other NHS Trusts might not have policies and procedures to prevent this type of error.
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 policies and procedures preventing failure to cap patent central venous catheter lines during patient mobilisation
Wider context from the report “That whilst the University Hospitals of Leicester(UHL) have taken adequate and acceptable steps following this incident to prevent this occurrence ever happening again. In particular the UHL have now adopted a policy of having bionectors at the end of patent lines instead of relying upon a simple bung and particular training for nurses in the correct and safe way to ensure safety of the lines whilst moving patients ensuring that this aspect has become a specific competency in training. However, I am concerned that other Trusts may not have such policies and procedure in place to prevent the inadvertent error of not capping a patent line of a central venous catheter during the mobilisation of a patient.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and publish dialysis guidance addressing safe haemodialysis catheter handling and air-embolism risks.
Verbatim wording from the response “Following this investigation, HSIB presented MHRA with a crucial safety recommendation: to amend its 2022 'Dialysis Guidance' to explicitly address the safety risk posed by unclamped haemodialysis catheters. The recommendation highlighted the necessity of updating guidelines to reflect emerging safety concerns and mitigate potential risks to patient safety. This call to action prompted MHRA to reassess and update its guidance to better address the specific challenges and risks associated with haemodialysis catheters.” Source location Response from Department of Health and Social Care
Open published response
7 Feb 2023 Ania Sohail · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 10 Lack of online pharmacy information sharing with patients’ GPs View source Lack of an integrated cross-pharmacy prescription alert system View source Ineffective searches of patients’ rooms for stockpiled medication View source Failure to document outcomes of negative personal searches View source Failure of 1:5 observation records to evidence five-minute checks View source Failure to identify and correct inaccurate Recovery and Discharge Plan information View source Failure to separately record post-leave assessment completion and outcomes View source Failure to prevent contraindicated prescribing across online and other prescribers View source Lack of mandatory refresher training in basic nursing care View source Failure of Recovery and Discharge Plans to address online medication procurement risks View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ania Sohail · 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
Ania Sohail collapsed on 19 June 2021 after ingesting Propranolol tablets she had obtained from multiple online pharmacies and died later that day from Propranolol toxicity. The principal concerns included the lack of integrated information sharing between online pharmacies and prescribers, ineffective and poorly documented searches, inadequate post-leave assessment and care planning, and insufficiently auditable observation records.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of online pharmacy information sharing with patients’ GPs
Wider context from the report “(2) There is no requirement for the on-line pharmacies to share information with the patient’s GP . This means that, in the absence of the patient’s consent to share information, the online prescriber is reliant on the accuracy and truthfulness of the history provided by the patient .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of an integrated cross-pharmacy prescription alert system
Wider context from the report “(1) Whilst each individual pharmacy had in-house safety checks to safeguard against over-prescribing by their own pharmacy, there is no integrated system in place which would alert a prescriber to prescriptions that have been dispensed by other on-line pharmacies . As a result, it is currently possible for a patient to obtain excessive quantities of medication by simply placing multiple orders with different on-line pharmacists.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 searches of patients’ rooms for stockpiled medication
Wider context from the report “(5) Searches undertaken on Ania’s room following the overdoses on 10 March and 5 June 2021 were ineffective and did not uncover the Propranolol that Ania had been stockpiling .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 document outcomes of negative personal searches
Wider context from the report “(4) There is no requirement for the outcome of negative personal searches to be documented in the records and consequently there is no ability to effectively audit whether searches are taking place and the treating team are unable to assess a patient’s level of compliance with rules around bringing contraband items onto the ward.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 1:5 observation records to evidence five-minute checks
Wider context from the report “(6) Documentation on which 1:5 observations are recorded does not evidence that a check has taken place every 5 minutes . Instead the current documentation, simply requires one signature per hour . There is therefore no mechanism by which observations can be effectively audited .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and correct inaccurate Recovery and Discharge Plan information
Wider context from the report “(1) The Recovery & Discharge Plans contained inaccurate information regarding Ania’s consent to share information with her mother . The evidence was that this was an entry made in error in June 2020 and was not picked up by any of the nurses who updated the Recovery & Discharge Plan over the subsequent 11 months .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 separately record post-leave assessment completion and outcomes
Wider context from the report “(7) There is no requirement to make a separate entry evidencing that a post-leave assessment has been undertaken . The post-leave assessments are currently subsumed within Day Notes and do not clearly state whether an assessment was undertaken, what was discussed and the outcome of the assessment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent contraindicated prescribing across online and other prescribers
Wider context from the report “(3) Lack of information sharing also creates a risk that a GP or Pharmacist Prescriber may unwittingly prescribe a medication that is contraindicated with a medication that has been dispensed through an on-line pharmacy .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 mandatory refresher training in basic nursing care
Wider context from the report “(3) Mandatory refresher training on basic aspects of nursing care such as record keeping, searches, care-planning, undertaking pre- and post-leave assessments and confidentiality is not provided to staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of Recovery and Discharge Plans to address online medication procurement risks
Wider context from the report “(2) The Recovery & Discharge Plans did not address the risks associated with Ania’s procurement of Propranolol from on-line pharmacies . The evidence was that an update of the Recovery & Discharge Plan involved members of nursing staff simply adding a note that the overdoses had taken place. The Plan did not show that any meaningful thought had been given to addressing the particular risk associated with the procurement of on-line 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 NHS England has no jurisdiction over private healthcare provision, including private online prescribing services.
Verbatim wording from the response “NHS England has no jurisdiction over private provision. Private providers would need a very good reason to breach a patient’s refusal to share their information as they are legally obliged to safeguard sensitive information under the General Data Protection Regulation. The General Pharmaceutical Council has provided information to online pharmacies on Providing medicines online, which is available at: Online Pharmacy Services (pharms.com)” Source location Response from Department of Health and Social Care
Open published response
4 Feb 2023 Patricia Grace Eileen Green · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Delays in Emergency Department assessment and treatment View source Delays in ambulance availability View source Delays in ambulance crew offload at Emergency Departments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Patricia Grace Eileen Green · 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
Patricia Grace Eileen Green had an accidental fall at home and remained prone on the floor for nine hours while waiting for an ambulance. She deteriorated, including in her breathing, and later died in hospital from COVID-19 pneumonia, with the investigation noting the fall and prolonged time on the floor as contributing factors. Concerns included delays in ambulance response and emergency department assessment, linked to shortages, high demand and delays transferring patients from emergency departments.
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 Emergency Department assessment and treatment
Wider context from the report “1. Mrs Green had a long wait for an ambulance, despite her age and the recognised risks of being on the floor for a prolonged period of time, due to a shortage of ambulances. Mrs Green deteriorated whilst waiting to be taken to hospital. The Inquest heard that the shortage of ambulances was due to a number of factors including high demand and a shortage of crews due to long delays at Emergency Departments (ED) across the Greater Manchester to offload patients;
2. The evidence before the Inquest was that the delay on the day Mrs Green was waiting for an ambulance was not unusual and still remained the case on the day of the Inquest;
3. The Inquest heard that Mrs Green’s wait of 3 hours in ED was not unusual and was due to the volume of patients waiting to be seen and the overall demand on ED . The consequence was that elderly frail patients were receiving treatment that was delayed and in circumstances that were challenging for frail patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 availability
Wider context from the report “1. Mrs Green had a long wait for an ambulance , despite her age and the recognised risks of being on the floor for a prolonged period of time, due to a shortage of ambulances . Mrs Green deteriorated whilst waiting to be taken to hospital. The Inquest heard that the shortage of ambulances was due to a number of factors including high demand and a shortage of crews due to long delays at Emergency Departments (ED) across the Greater Manchester to offload patients;
2. The evidence before the Inquest was that the delay on the day Mrs Green was waiting for an ambulance was not unusual and still remained the case on the day of the Inquest ;
3. The Inquest heard that Mrs Green’s wait of 3 hours in ED was not unusual and was due to the volume of patients waiting to be seen and the overall demand on ED. The consequence was that elderly frail patients were receiving treatment that was delayed and in circumstances that were challenging for frail patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 crew offload at Emergency Departments
Wider context from the report “1. Mrs Green had a long wait for an ambulance, despite her age and the recognised risks of being on the floor for a prolonged period of time, due to a shortage of ambulances. Mrs Green deteriorated whilst waiting to be taken to hospital. The Inquest heard that the shortage of ambulances was due to a number of factors including high demand and a shortage of crews due to long delays at Emergency Departments (ED) across the Greater Manchester to offload patients ;
2. The evidence before the Inquest was that the delay on the day Mrs Green was waiting for an ambulance was not unusual and still remained the case on the day of the Inquest;
3. The Inquest heard that Mrs Green’s wait of 3 hours in ED was not unusual and was due to the volume of patients waiting to be seen and the overall demand on ED. The consequence was that elderly frail patients were receiving treatment that was delayed and in circumstances that were challenging for frail patients.
” 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 NWAS 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 Scale 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 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 5,000 additional staffed, permanent hospital beds and maintain the 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 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 Maintain additional ambulance capacity to expand provision and improve response times.
Verbatim wording from the response “Your report highlights that NWAS 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 Provide funding to support timely and effective discharge from hospital.
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 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
4 Feb 2023 Benjamin Paul Stanley · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Insufficient hospital bed capacity View source Delays in patients being seen in Accident and Emergency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Benjamin Paul Stanley · 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
Benjamin Paul Stanley developed chronic pancreatitis, became severely malnourished, and was admitted to Stepping Hill Hospital on 11 May 2022. He deteriorated, developing liver cirrhosis, sepsis and a Clostridium difficile infection, and died in hospital on 19 May 2022. The concerns identified included prolonged waits in A&E linked to demand and a lack of beds; in his case, direct entry to a ward was considered to have been in his best interests, but he had to wait in A&E for a bed.
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 hospital bed capacity
Wider context from the report “The Inquest heard evidence of significant waits in Accident and Emergency (A&E) to be seen due to the pressure on the department. The Inquest heard that the hospital had not improved since his death and there were regular waits in excess of 11 hours in A&E due to demand on services which impacted on patients care and treatment. The position was not unique to the particular Trust but was replicated in Trusts across Greater Manchester.
The Inquest was told that prolonged waits in A&E were also due to a lack of beds with the hospital . In Mr Stanley’s case direct entry to a ward would have been in his best interests. However lack of capacity meant that he had to be advised to go to A&E and wait for a bed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in patients being seen in Accident and Emergency
Wider context from the report “The Inquest heard evidence of significant waits in Accident and Emergency (A&E) to be seen due to the pressure on the department . The Inquest heard that the hospital had not improved since his death and there were regular waits in excess of 11 hours in A&E due to demand on services which impacted on patients care and treatment . The position was not unique to the particular Trust but was replicated in Trusts across Greater Manchester.
The Inquest was told that prolonged waits in A&E were also due to a lack of beds with the hospital. In Mr Stanley’s case direct entry to a ward would have been in his best interests. However lack of capacity meant that he had to be advised to go to A&E and wait for a bed.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a delivery plan to recover urgent and emergency care services and improve emergency waiting times.
Verbatim wording from the response “As the Minister responsible for urgent and emergency case services, I recognise the pressures our A&E services are facing and the impact on waiting times for patients. That is why we published our delivery plan for recovering urgent and emergency care services which aims to deliver sustained improvements in emergency waiting times. The ambition is to improve A&E wait times to 78% of patients being admitted, transferred, or discharged within four hours by March 2025.” 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 £1.6 billion available over two years to support timely hospital discharge and free beds.
Verbatim wording from the response “We recognise that a whole-system approach is needed to ensure people get the emergency care they need when they need it. This is why we have made £1.6 billion of funding available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E. NHS England also launched its universal support offer, available to all systems, including Stockport NHS Foundation Trust which supported systems to implement high impact initiatives and improve emergency care performance ahead of winter 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 Deliver 5,000 additional staffed, permanent hospital beds to increase capacity and improve patient flow.
Verbatim wording from the response “A key part of the plan has been to increase hospital capacity to improve patient flow and reduce overcrowding in A&E. We have achieved the ambition of delivering 5,000 more staffed, permanent beds this year compared to 2022-23 plans - backed by £1” Source location Response from Department of Health and Social Care
Open published response
27 Jan 2023 Toby Wilbur Barwick · Prevention of Future Deaths report East London
View report summary
Concerns raised 1 Failure to provide maternity discharge advice and documentation on SIDS and recommended safe practices 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
Toby Wilbur Barwick · 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
Toby Wilbur Barwick was born on 24 November 2020 and died in hospital on 12 February 2021 after being found unresponsive while sleeping in a fabric baby carrier. The inquest heard that his parents did not receive advice and documentation from UCLH about SIDS and recommended safe practices, and UCLH could not provide clear evidence that the factors leading to this omission had been remedied.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide maternity discharge advice and documentation on SIDS and recommended safe practices
Wider context from the report “1. The inquest heard that infants of low birth weight have a higher chance of dying in circumstances of Sudden Infant Death Syndrome (“SIDS”). Upon discharge from a maternity unit mother should receive advice and documentation upon a number of issues including (but not limited to) SIDS and recommended safe practices to reduce risk. Mr & Mrs Barwick did not receive this material at UCLH. UCLH could not provide clear evidence that the factors that led to this omission had been successfully remedied.
” Open source report
26 Jan 2023 Matthew Harter DALE · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1 Failure to maintain a shared understanding of care funding and provision across agencies 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
Matthew Harter DALE · 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
Matthew Harter DALE died after swallowing part of an incontinence pad while unsupervised; the item became trapped in his airway. The death was partly contributed to by a missed opportunity to increase supervision, amid confusion between commissioning and care agencies about the care and supervision that should have been provided.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a shared understanding of care funding and provision across agencies
Wider context from the report “It became clear in the inquest that the commission, funding, assessment and provision of care needs is a complex process involving, particularly as in Matthews case, where there are multiple agencies involved due to his own complex and multifaceted needs. In this case it has been established that there was a confusion over the care in how it was funded and expected to be provided, compared to that which was understood to be funded and actually provided on the ground to Matthew . The confusion appears to have arisen over the understanding of a number of care terms and the use of them which has resulted in 2 commissioning agencies and an agency providing the care having differing views about Matthews care and that which should have been in place and that which was in place .
” Open source report
25 Jan 2023 Rita Maureen TAYLOR · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 2 Insufficient ambulance service resources for emergency response demand View source Failure to upgrade emergency incident categorisation when clinical deterioration warranted a higher priority 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
Rita Maureen TAYLOR · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Rita Maureen TAYLOR suffered an unwitnessed fall at home and a head injury. Multiple ambulance calls were made, but an ambulance was delayed because no resources were available; she arrived at hospital with a Glasgow Coma Score of 3 and died the same day. The principal concern was insufficient ambulance service resources and the resulting delay, which the inquest conclusion described as causing lost opportunities to admit her and begin 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 Insufficient ambulance service resources for emergency response demand
Wider context from the report “I am concerned that there are insufficient ambulance service resources to meet the needs of the City of Milton Keynes.
The first call to the 111 service was made at 10.28 and the call was deemed a category 3 incident. [At] that time there were "no available resources to send."
At 11.12 a 999 call was made by a passer by but there were still "no available resources ".
At 12.16 there was a further 999 call. The incident remained a category three and was "still pending in the dispatch queue waiting for resources to become available ".
At 12.41 a call was made to Mrs. Taylor’s location but there were " still no available resources to send" .
At 13.12 A further 999 call was made " awaiting resources to become available"
At 13.48 Patient location was called she was now in and out of consciousness and although she remained a category 3 an audit of the call decided that she should have been upgraded to a category 2 or 1. "Still no available resources" .
At 14.42 further 999 call but again "no available resources" .
At 15.25 Case reviewed to a category 2.
At 16.29 An ambulance was dispatched arriving at 17.15. This was 6hours 47 minutes after the original call and 1hour 49 minutes after category 2 upgrade.
Mrs Taylor arrived at the hospital at 17.57 and when assessed in the emergency department her Glasgow Coma score was recorded as 3.She died later the same day.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 upgrade emergency incident categorisation when clinical deterioration warranted a higher priority
Wider context from the report “I am concerned that there are insufficient ambulance service resources to meet the needs of the City of Milton Keynes.
The first call to the 111 service was made at 10.28 and the call was deemed a category 3 incident. [At] that time there were "no available resources to send."
At 11.12 a 999 call was made by a passer by but there were still "no available resources ".
At 12.16 there was a further 999 call. The incident remained a category three and was "still pending in the dispatch queue waiting for resources to become available ".
At 12.41 a call was made to Mrs. Taylor’s location but there were " still no available resources to send".
At 13.12 A further 999 call was made " awaiting resources to become available"
At 13.48 Patient location was called she was now in and out of consciousness and although she remained a category 3 an audit of the call decided that she should have been upgraded to a category 2 or 1. "Still no available resources".
At 14.42 further 999 call but again "no available resources".
At 15.25 Case reviewed to a category 2.
At 16.29 An ambulance was dispatched arriving at 17.15. This was 6hours 47 minutes after the original call and 1hour 49 minutes after category 2 upgrade.
Mrs Taylor arrived at the hospital at 17.57 and when assessed in the emergency department her Glasgow Coma score was recorded as 3.She died later the same day.
” Open source report
20 Jan 2023 Sophia Ayuk · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Failure to assess inpatient patients for venous thromboembolism risk View source Failure to adequately monitor and record patients’ food and fluid intake 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
Sophia Ayuk · 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
Sophia Ayuk, who had treatment-resistant schizophrenia and was an inpatient, became motionless and unresponsive on 18 March 2022, later deteriorated and died despite resuscitation. The inquest narrative attributed her death to a pulmonary embolism following a deep vein thrombosis, and recorded that she had not taken food or drink for at least two days. The principal concerns were that VTE risk was not assessed during either period of inpatient care and that food and fluid intake monitoring was not adequately followed.
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 assess inpatient patients for venous thromboembolism risk
Wider context from the report “1. At no time during the two periods of Ms Ayuk’s inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately monitor and record patients’ food and fluid intake
Wider context from the report “2. Instructions given to monitor and record Ms Ayuk’s food and fluid intake were not adequately followed .
” Open source report
20 Jan 2023 Dorothy Anne Jones · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 4 Allocation of Amber 1 ambulance resources chronologically without further consideration of clinical need View source Ad hoc clinician intervention to expedite ambulance responses without local policy or guidelines View source Failure of the current ambulance triage algorithm to assign appropriate urgency to choking, breathing difficulty and drowsiness View source Failure to provide ambulance resources to Amber 1 patients within a reasonable timeframe 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
Dorothy Anne Jones · 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
Dorothy Anne Jones developed a chest infection and was assessed at home as needing immediate hospital admission. An ambulance did not attend until over nine hours after it was requested, and paramedics found that she had died. The report identified concerns about ambulance response times for Amber 1 patients, chronological allocation without further consideration of clinical need, and an ad hoc process for expediting responses.
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 Allocation of Amber 1 ambulance resources chronologically without further consideration of clinical need
Wider context from the report “2. The Amber 1 category includes all life-threatening conditions except those in the Red category where the person appears to be in the throes of dying. I was informed that all the patients in the Amber 1 category are allocated an ambulance / clinical resource chronologically, without further consideration of clinical need .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Ad hoc clinician intervention to expedite ambulance responses without local policy or guidelines
Wider context from the report “3. I was informed at the inquest that on occasion a clinician within WAST will intervene to undertake a further assessment to determine whether the response should be expedited . However, this appeared to be an ad hoc arrangement not underpinned by local policy or guidelines .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of the current ambulance triage algorithm to assign appropriate urgency to choking, breathing difficulty and drowsiness
Wider context from the report “4. The evidence suggested that a patient who was choking, had difficulty breathing and was drowsy would still be assessed , under the current algorithm adopted by WAST, as meeting the requirement for an Amber 1 response .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide ambulance resources to Amber 1 patients within a reasonable timeframe
Wider context from the report “1. The ongoing pressures faced by the ambulance service are clearly multifactorial. However, a failure to provide a resource within a reasonable timeframe has been a constant and ongoing feature of inquests within Gwent , where a patient has died at home or shortly after admission to hospital. Despite repeated reassurances over the past 12 months about remedial action being undertaken, the evidence before me at this inquest suggests there has been no appreciable improvement in the response times for Amber 1 category patients .
” Open source report
19 Jan 2023 Lance Scott Walker · Prevention of Future Deaths report West London
View report summary
Concerns raised 9 Insufficient scrutiny and approval of new accommodation providers View source Lack of regulatory oversight of supported accommodation for 18-21 year olds View source Lack of a standard referral form for supported housing service users aged 16-25 View source Insufficient contractual oversight of accommodation providers View source Insufficient provider knowledge of complex resident needs View source Inadequate checking and auditing of placement forms and referral information View source Inadequate staffing in supported accommodation View source Failure to perform adequate due diligence when matching individuals in accommodation View source Inadequate training among supported accommodation providers View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lance Scott Walker · 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
Lance Scott Walker, an 18-year-old looked-after child, was placed in unregulated accommodation in 2016, where another 18-year-old resident was later placed. Eleven days after they were placed together, the other resident fatally stabbed Lance in the afternoon of 15 August 2016. Concerns included the use and oversight of unregulated accommodation, inadequate assessment and communication of the other resident’s risks and needs, shortcomings in placement and provider due diligence, and failures in information-sharing and management.
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 scrutiny and approval of new accommodation providers
Wider context from the report “3 Response from London Borough of Ealing
The Court was advised that the inquest had raised several points that will be further considered but that have not yet been addressed following this tragic death. In particular, system review of the “due diligence” in matching of individuals in the accommodation needs to be carried out and further lessons can be learnt in relation to the Borough’s obligations in this regard. Strengthening the contractual elements between the Borough and Providers would ensure additional oversight of these relationships. Additional work in double checking and auditing placement forms needs further review to learn from the issues encountered in this case, and to improve the consistency and standard of referrals, with consideration on the introduction of mandatory fields for specific information to be included. The Borough undertook to enhance “New provider” scrutiny and approval in the light of the inquest findings. Confirmation of these positive steps and actions should be provided to allay the jury and Court’s concerns arising from this inquiry.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 regulatory oversight of supported accommodation for 18-21 year olds
Wider context from the report “1 Response requested from Secretary of State for Education and Secretary of State for Health and Social Care
Lance was only exposed to his killer because he was obliged to live in the designated accommodation. Although the 2 relevant Councils were duty bound to house both individuals up until the age of 21 under the Leaving Care Act, there is currently no provision for the over 18’s. Regulation is being introduced for 16-17 year olds in April 2023.
Both Councils were in agreement that Regulation of this sector would be welcomed to support them in carrying out their statutory obligations. A set of minimum requirements to introduce clear guidance across the sector would benefit the residents, the providers and all stakeholders in this particularly challenging sector. Currently OFSTED does not have an obligation to be involved and this falls outside the CQC’s regulation as the provision is not for “care” but support. The provision is made from an entirely un-regulated sector , resulting in some organisations offering accommodation with inadequate training, staffing or knowledge to meet the complex needs of some of our most vulnerable individuals. Consideration should be given to introducing regulation for at least 18-21 year old individuals. This issue remains a concern for all those who work within it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 standard referral form for supported housing service users aged 16-25
Wider context from the report “2 Response requested from London Borough of Ealing, London Borough of Islington and the West London Alliance
There is currently no standard referral form for service users aged 16-25 to be referred into supported housing. This means that best practise is not universally followed and it is more difficult for stakeholders to have to deal with a number of different forms. Vital information can potentially be missed and issues not highlighted when a variety of forms are used for the same referral procedure. Consideration should be given to adopting a standard form across the West London Alliance, or even a national standard using “best practise” as the benchmark, for clarity and ease of reference.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 contractual oversight of accommodation providers
Wider context from the report “3 Response from London Borough of Ealing
The Court was advised that the inquest had raised several points that will be further considered but that have not yet been addressed following this tragic death. In particular, system review of the “due diligence” in matching of individuals in the accommodation needs to be carried out and further lessons can be learnt in relation to the Borough’s obligations in this regard. Strengthening the contractual elements between the Borough and Providers would ensure additional oversight of these relationships. Additional work in double checking and auditing placement forms needs further review to learn from the issues encountered in this case, and to improve the consistency and standard of referrals, with consideration on the introduction of mandatory fields for specific information to be included. The Borough undertook to enhance “New provider” scrutiny and approval in the light of the inquest findings. Confirmation of these positive steps and actions should be provided to allay the jury and Court’s concerns arising from this inquiry.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 provider knowledge of complex resident needs
Wider context from the report “1 Response requested from Secretary of State for Education and Secretary of State for Health and Social Care
Lance was only exposed to his killer because he was obliged to live in the designated accommodation. Although the 2 relevant Councils were duty bound to house both individuals up until the age of 21 under the Leaving Care Act, there is currently no provision for the over 18’s. Regulation is being introduced for 16-17 year olds in April 2023.
Both Councils were in agreement that Regulation of this sector would be welcomed to support them in carrying out their statutory obligations. A set of minimum requirements to introduce clear guidance across the sector would benefit the residents, the providers and all stakeholders in this particularly challenging sector. Currently OFSTED does not have an obligation to be involved and this falls outside the CQC’s regulation as the provision is not for “care” but support. The provision is made from an entirely un-regulated sector, resulting in some organisations offering accommodation with inadequate training, staffing or knowledge to meet the complex needs of some of our most vulnerable individuals. Consideration should be given to introducing regulation for at least 18-21 year old individuals. This issue remains a concern for all those who work within it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 checking and auditing of placement forms and referral information
Wider context from the report “3 Response from London Borough of Ealing
The Court was advised that the inquest had raised several points that will be further considered but that have not yet been addressed following this tragic death. In particular, system review of the “due diligence” in matching of individuals in the accommodation needs to be carried out and further lessons can be learnt in relation to the Borough’s obligations in this regard. Strengthening the contractual elements between the Borough and Providers would ensure additional oversight of these relationships. Additional work in double checking and auditing placement forms needs further review to learn from the issues encountered in this case, and to improve the consistency and standard of referrals , with consideration on the introduction of mandatory fields for specific information to be included . The Borough undertook to enhance “New provider” scrutiny and approval in the light of the inquest findings. Confirmation of these positive steps and actions should be provided to allay the jury and Court’s concerns arising from this inquiry.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 staffing in supported accommodation
Wider context from the report “1 Response requested from Secretary of State for Education and Secretary of State for Health and Social Care
Lance was only exposed to his killer because he was obliged to live in the designated accommodation. Although the 2 relevant Councils were duty bound to house both individuals up until the age of 21 under the Leaving Care Act, there is currently no provision for the over 18’s. Regulation is being introduced for 16-17 year olds in April 2023.
Both Councils were in agreement that Regulation of this sector would be welcomed to support them in carrying out their statutory obligations. A set of minimum requirements to introduce clear guidance across the sector would benefit the residents, the providers and all stakeholders in this particularly challenging sector. Currently OFSTED does not have an obligation to be involved and this falls outside the CQC’s regulation as the provision is not for “care” but support. The provision is made from an entirely un-regulated sector, resulting in some organisations offering accommodation with inadequate training, staffing or knowledge to meet the complex needs of some of our most vulnerable individuals. Consideration should be given to introducing regulation for at least 18-21 year old individuals. This issue remains a concern for all those who work within it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 perform adequate due diligence when matching individuals in accommodation
Wider context from the report “3 Response from London Borough of Ealing
The Court was advised that the inquest had raised several points that will be further considered but that have not yet been addressed following this tragic death. In particular, system review of the “due diligence” in matching of individuals in the accommodation needs to be carried out and further lessons can be learnt in relation to the Borough’s obligations in this regard. Strengthening the contractual elements between the Borough and Providers would ensure additional oversight of these relationships. Additional work in double checking and auditing placement forms needs further review to learn from the issues encountered in this case, and to improve the consistency and standard of referrals, with consideration on the introduction of mandatory fields for specific information to be included. The Borough undertook to enhance “New provider” scrutiny and approval in the light of the inquest findings. Confirmation of these positive steps and actions should be provided to allay the jury and Court’s concerns arising from this inquiry.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate training among supported accommodation providers
Wider context from the report “1 Response requested from Secretary of State for Education and Secretary of State for Health and Social Care
Lance was only exposed to his killer because he was obliged to live in the designated accommodation. Although the 2 relevant Councils were duty bound to house both individuals up until the age of 21 under the Leaving Care Act, there is currently no provision for the over 18’s. Regulation is being introduced for 16-17 year olds in April 2023.
Both Councils were in agreement that Regulation of this sector would be welcomed to support them in carrying out their statutory obligations. A set of minimum requirements to introduce clear guidance across the sector would benefit the residents, the providers and all stakeholders in this particularly challenging sector. Currently OFSTED does not have an obligation to be involved and this falls outside the CQC’s regulation as the provision is not for “care” but support. The provision is made from an entirely un-regulated sector, resulting in some organisations offering accommodation with inadequate training , staffing or knowledge to meet the complex needs of some of our most vulnerable individuals. Consideration should be given to introducing regulation for at least 18-21 year old individuals. This issue remains a concern for all those who work within it.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations