26 Aug 2022 Christopher Michael Lloyd · Prevention of Future Deaths report Manchester South
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Concerns raised 1 Lack of ready local access to a dual-diagnosis service View source
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Christopher Michael Lloyd · 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 Michael Lloyd died at home after suspending himself by the neck with a ligature. The principal concern was that, despite interactions with mental health services and support for alcohol and drug addiction, he did not have ready local access to a dual-diagnosis service for co-existing mental-health and substance-misuse issues.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of ready local access to a dual-diagnosis service
Wider context from the report “1. Whilst Mr Lloyd had some interactions with mental health services, and was under the care of a charity who provides support as a consequence of alcohol and drug addiction, it is a matter of concern that he did not have ready access to a dual-diagnosis service locally .
A unified service of this nature, employing appropriate specialists, would have the benefit of being able to assess and treat mental-health conditions existing alongside substance misuse issues in a coherent and holistic manner.
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £532 million to local authorities to increase and improve drug treatment services.
Verbatim wording from the response “Moreover, the Government published From harm to hope: a 10-year Drug Strategy in-response to Dame Carol Black’s independent review on drugs.⁵ One of the three priorities of this strategy is to deliver a world-class treatment and recovery system, backed by an additional £780m over three years. Of this, £532 million has been made available to local authorities to increase and improve treatment services to reduce harm and improve recovery rate significantly. This will include better integrating treatment services to ensure people’s mental and physical health needs are met. OHID is also currently working with NHS England and the wider sector to identify ways to improve the integration of services, including better implementation of the existing guidance.” Source location Response from Department of Health and Social Care
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with NHS England and the wider sector to identify improvements to service integration and implementation of existing guidance.
Verbatim wording from the response “Moreover, the Government published From harm to hope: a 10-year Drug Strategy in-response to Dame Carol Black’s independent review on drugs.⁵ One of the three priorities of this strategy is to deliver a world-class treatment and recovery system, backed by an additional £780m over three years. Of this, £532 million has been made available to local authorities to increase and improve treatment services to reduce harm and improve recovery rate significantly. This will include better integrating treatment services to ensure people’s mental and physical health needs are met. OHID is also currently working with NHS England and the wider sector to identify ways to improve the integration of services, including better implementation of the existing guidance.” Source location Response from Department of Health and Social Care
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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 for commissioners and providers on co-occurring mental health and substance use conditions.
Verbatim wording from the response “The Office for Health Improvement and Disparities (OHID) has previously published Better Care for People with Co-Occurring Mental Health and Alcohol/Drug Use Conditions, a guide for commissioners and services providers informed by clinical evidence and expertise.¹ Two principles from that guide, which should be followed routinely, are that people with co-” Source location Response from Department of Health and Social Care
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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 10-year drug strategy to deliver an improved treatment and recovery system.
Verbatim wording from the response “Moreover, the Government published From harm to hope: a 10-year Drug Strategy in-response to Dame Carol Black’s independent review on drugs.⁵ One of the three priorities of this strategy is to deliver a world-class treatment and recovery system, backed by an additional £780m over three years. Of this, £532 million has been made available to local authorities to increase and improve treatment services to reduce harm and improve recovery rate significantly. This will include better integrating treatment services to ensure people’s mental and physical health needs are met. OHID is also currently working with NHS England and the wider sector to identify ways to improve the integration of services, including better implementation of the existing guidance.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Separate dual-diagnosis treatment services are not supported by evidence and are not recommended in published guidance.
Verbatim wording from the response “In response to your recommendation for further, separate provision of specific dual diagnosis treatment services alongside mental health and substance misuse services, it is important to point out such service structures are not backed by evidence and so not recommended in the published guidance.” Source location Response from Department of Health and Social Care
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17 Aug 2022 Philip Jones · Prevention of Future Deaths report Manchester South
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Concerns raised 3 Significant backlogs in appointments for neurology assessment View source Failure of IT systems across healthcare organisations to support shared access to complete patient information View source Delays in consultants communicating diagnostic and treatment information after appointments or assessments View source
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Philip 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
Philip Jones developed difficulty swallowing in February 2021, lost significant weight, and was diagnosed with Motor Neurone Disease after hospital admission in September 2021. He developed bronchopneumonia, deteriorated, was discharged home, and died there on 9 October 2021. Concerns included backlogs for neurology appointments, incompatible IT systems affecting information sharing, and delays in communications from consultants to other clinicians and patients.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Significant backlogs in appointments for neurology assessment
Wider context from the report “1. The Inquest heard evidence that there were significant backlogs in appointments to see a neurologist due to a national shortage of clinicians and appointments. In Mr Jones’ case this had not impacted the overall outcome but the Inquest heard evidence that this would not necessarily be the case in all patients. The Inquest heard that pre-pandemic, there was a backlog in existence at 3,500 patients waiting for a neurology appointment . The figure at the time of the Inquest was approx. 7,000 ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 IT systems across healthcare organisations to support shared access to complete patient information
Wider context from the report “2. The Inquest heard evidence that incompatible/different IT systems at the District General Hospital and Tertiary Centre made communication and information sharing in relation to patients more difficult . This impacted the holistic view that clinicians needed of an individual patient . Whilst images could be shared there was no ability for notes for one Trust to be visible to a clinician at another Trust ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 consultants communicating diagnostic and treatment information after appointments or assessments
Wider context from the report “3. The Inquest heard that there were delays in communications from consultants to other clinicians e.g. GPs and patients following appointments/assessments due to a shortage of administrative support for consultants . This meant that important diagnostic/treatment information about patients was not shared expeditiously .
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase NHS workforce capacity to address rising demand for health and care services.
Verbatim wording from the response “I also note your concern about the shortage of neurological clinicians. We have increased the size of the NHS workforce over the last decade and this growth continues to be a key focus to ensure we meet the rise in demand for health and care services. Looking at the workforce of the future, the Department has commissioned Health Education England to work with system partners and review long term strategic trends for the health and regulated social care workforce, and have commissioned NHS England to develop a long-term workforce plan.” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission NHS England to develop a long-term workforce plan.
Verbatim wording from the response “I also note your concern about the shortage of neurological clinicians. We have increased the size of the NHS workforce over the last decade and this growth continues to be a key focus to ensure we meet the rise in demand for health and care services. Looking at the workforce of the future, the Department has commissioned Health Education England to work with system partners and review long term strategic trends for the health and regulated social care workforce, and have commissioned NHS England to develop a long-term workforce plan.” Source location Response from Department of Health and Social Care
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a plan for digital health and social care to modernise digital technology and improve data use and care pathways.
Verbatim wording from the response “You may wish to note that the Spending Review, announced in Autumn 2021, included £2.1 billion to modernise digital technology on the frontline to improve cyber security, improve the NHS’s use of data, and redesign care pathways. As well as a funding” Source location Response from Department of Health and Social Care
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Build digital infrastructure using artificial intelligence, automation and video-call technologies to support NHS services.
Verbatim wording from the response “I also note your concern that incompatible IT systems between the hospitals in question made communication and information sharing in relation to Mr Jones’s treatment more difficult, as did the delay in the consultants communicating with other clinicians, including GPs, and as well as the patients themselves. I recognise that there needs to be adequate administrative support and greater use of digital technology to assist healthcare workers in completing non-clinical tasks, and that could increase the time they can spend caring for patients. This would provide a better patient experience and, ultimately, improve health outcomes.” Source location Response from Department of Health and Social Care
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12 Aug 2022 Helen Ruth BURNELL · Prevention of Future Deaths report Somerset
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Concerns raised 1 Failure of staff to adequately recognise choking risks View source
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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
Helen Ruth BURNELL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Helen Ruth Burnell choked on a sandwich while eating dinner and suffered a fatal hypoxic brain injury after respiratory and cardiac arrest. The report raised concerns that staff had not adequately recognised choking risks and that improved training was needed to support adherence to meal-time recommendations.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to adequately recognise choking risks
Wider context from the report “1) I identified that better training should be given to staff in respect of choking risks. Choking is a serious health and safety risk and concern for adults with autism and those with learning disabilities. The risk of choking does not appear to have been adequately recognised by staff.
(2) Improved training of staff, care givers and their respective managers may have the potential to increase adherence to meal time recommendations and lessen the risk of choking.
” Open source report
7 Aug 2022 Robyn Lily Audrey SKILTON · Prevention of Future Deaths report West Sussex
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Concerns raised 3 Delays in tier 3 CAMHS acceptance View source Lack of resourcing and provision for young people’s mental health services View source Delays in specialist child mental health assessment View source
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Robyn Lily Audrey SKILTON · 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
On 7 May 2021, 14-year-old Robyn Lily Audrey Skilton was found in Southwater Park with a ligature around her neck, and her death was confirmed by emergency services. The inquest concluded that Robyn took her own life while struggling with her mental health, and that mental health services failed to recognise the deterioration in her mental health or provide the care and treatment she required. The report raised concerns about delayed assessment and treatment, including a lack of timely access to Child Psychiatrist and CAMHS services and insufficient resourcing.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in tier 3 CAMHS acceptance
Wider context from the report “Robyn was failed by the Mental Health Services quite frankly due to the current lack of resourcing and provision in place to support young people struggling with their mental health. Due to the lack of availability of a Child Psychiatrist there are long waiting times for children to be assessed. Robyn was not seen by a Child Psychiatrist and/or Psychologist, despite there being a need for this to happen, thereby enabling her to be diagnosed and receive a treatment plan. Robyn’s parents did everything they could during this period to support Robyn, including paying for a private counsellor, but sadly Robyn’s mental health continued to deteriorate during this time, and she took her own life. Robyn initial acceptance into tier 3 Children and Mental Health Services (CAMHS) similarly did not happen in a timely manner.
I do appreciate that the landscape that the local mental health Trust (Sussex Partnership Foundation Trust) was working under and the fact that Covid heightened the level of complexity across many services but there were many failings in the care provided to Robyn.
It became very clear during the Inquest that there is significant under funding of the local mental health Trusts who like many mental health Trusts see an explosion of referrals to their Children and Mental Health services (CAMHS).
By way of an example:-
Referrals to West Sussex CAMHS have increased by 95.6% from May 2019 (389) to May 2022 (761)
West Sussex CAMHS caseload has increased by 85% from May 2019 (2239) to May 2022 (4147)
West Sussex CAMHS Duty caseload has increased by 112% from May 2021 (492) to May 2022 (1494)
Mental Health A&E presentations, in period April 2021 - March 2022, have increased by 40% on previous year (April 2020 - March 2021).
Additionally, across Sussex CAMHS, as a whole, the referrals data shows:-
• May 2022 was the highest number of referrals the service has ever received (1350).
• Of those 1350 referrals, 80% (1,081) were accepted into the service.
• In comparison, in May 2019, 579 were accepted (65% accepted)
• So, an additional 502 young people have been accepted in May 2022 compared to May 2019
Despite the increase in numbers accessing CAMHS there has not been any relative increase in resources to meet this demand and therefore the current position is is unsustainable and it is putting many young people’s lives at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of resourcing and provision for young people’s mental health services
Wider context from the report “Robyn was failed by the Mental Health Services quite frankly due to the current lack of resourcing and provision in place to support young people struggling with their mental health . Due to the lack of availability of a Child Psychiatrist there are long waiting times for children to be assessed. Robyn was not seen by a Child Psychiatrist and/or Psychologist, despite there being a need for this to happen, thereby enabling her to be diagnosed and receive a treatment plan. Robyn’s parents did everything they could during this period to support Robyn, including paying for a private counsellor, but sadly Robyn’s mental health continued to deteriorate during this time, and she took her own life. Robyn initial acceptance into tier 3 Children and Mental Health Services (CAMHS) similarly did not happen in a timely manner.
I do appreciate that the landscape that the local mental health Trust (Sussex Partnership Foundation Trust) was working under and the fact that Covid heightened the level of complexity across many services but there were many failings in the care provided to Robyn.
It became very clear during the Inquest that there is significant under funding of the local mental health Trusts who like many mental health Trusts see an explosion of referrals to their Children and Mental Health services (CAMHS).
By way of an example:-
Referrals to West Sussex CAMHS have increased by 95.6% from May 2019 (389) to May 2022 (761)
West Sussex CAMHS caseload has increased by 85% from May 2019 (2239) to May 2022 (4147)
West Sussex CAMHS Duty caseload has increased by 112% from May 2021 (492) to May 2022 (1494)
Mental Health A&E presentations, in period April 2021 - March 2022, have increased by 40% on previous year (April 2020 - March 2021).
Additionally, across Sussex CAMHS, as a whole, the referrals data shows:-
• May 2022 was the highest number of referrals the service has ever received (1350).
• Of those 1350 referrals, 80% (1,081) were accepted into the service.
• In comparison, in May 2019, 579 were accepted (65% accepted)
• So, an additional 502 young people have been accepted in May 2022 compared to May 2019
Despite the increase in numbers accessing CAMHS there has not been any relative increase in resources to meet this demand and therefore the current position is is unsustainable and it is putting many young people’s lives at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in specialist child mental health assessment
Wider context from the report “Robyn was failed by the Mental Health Services quite frankly due to the current lack of resourcing and provision in place to support young people struggling with their mental health. Due to the lack of availability of a Child Psychiatrist there are long waiting times for children to be assessed. Robyn was not seen by a Child Psychiatrist and/or Psychologist, despite there being a need for this to happen , thereby enabling her to be diagnosed and receive a treatment plan. Robyn’s parents did everything they could during this period to support Robyn, including paying for a private counsellor, but sadly Robyn’s mental health continued to deteriorate during this time, and she took her own life. Robyn initial acceptance into tier 3 Children and Mental Health Services (CAMHS) similarly did not happen in a timely manner.
I do appreciate that the landscape that the local mental health Trust (Sussex Partnership Foundation Trust) was working under and the fact that Covid heightened the level of complexity across many services but there were many failings in the care provided to Robyn.
It became very clear during the Inquest that there is significant under funding of the local mental health Trusts who like many mental health Trusts see an explosion of referrals to their Children and Mental Health services (CAMHS).
By way of an example:-
Referrals to West Sussex CAMHS have increased by 95.6% from May 2019 (389) to May 2022 (761)
West Sussex CAMHS caseload has increased by 85% from May 2019 (2239) to May 2022 (4147)
West Sussex CAMHS Duty caseload has increased by 112% from May 2021 (492) to May 2022 (1494)
Mental Health A&E presentations, in period April 2021 - March 2022, have increased by 40% on previous year (April 2020 - March 2021).
Additionally, across Sussex CAMHS, as a whole, the referrals data shows:-
• May 2022 was the highest number of referrals the service has ever received (1350).
• Of those 1350 referrals, 80% (1,081) were accepted into the service.
• In comparison, in May 2019, 579 were accepted (65% accepted)
• So, an additional 502 young people have been accepted in May 2022 compared to May 2019
Despite the increase in numbers accessing CAMHS there has not been any relative increase in resources to meet this demand and therefore the current position is is unsustainable and it is putting many young people’s lives at risk.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest additional funding to expand children’s mental health services and increase access to community and eating disorder services.
Verbatim wording from the response “This is why, in 2021/22 we provided an additional £79million to expand children’s mental health services, allowing around 22,500 more children and young people to access community health services, 2,000 more to access eating disorder services, as well as a faster increase in the coverage of mental health support teams in schools and colleges. There are currently 287 mental health support teams supporting schools and colleges, covering 20-25% of the country, with 13 planned or in operation across the Sussex integrated care system.” Source location Response from department of Health and Social Care
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand and strengthen the NHS mental health workforce, including adding 27,000 mental health professionals by 2023/24.
Verbatim wording from the response “Growth of the mental health workforce, as well as retaining and re-skilling our current workforce, is the key strategic priority to ensure we can deliver our commitments to expand services and increase access. This is why, through the Plan we are committed to expanding the NHS workforce, with an aim of having and additional 27,000 mental health professionals by 2023/24, to deliver the expansion and transformation of mental health services, including those for children and young people.” Source location Response from department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with NHS England on next steps following consultation on proposed mental health waiting-time standards.
Verbatim wording from the response “More broadly, NHS England consulted on the potential to introduce a range of new waiting time standards as part of its Clinically-led Review of NHS Access Standards⁴. These include:” Source location Response from department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local commissioners are responsible for commissioning healthcare services that meet local population needs and expanding mental health services.
Verbatim wording from the response “A significant portion of this funding is provided through baseline funding to local commissioners (formerly clinical commissioning groups and now through the integrated care boards that replaced them). This is supporting them to deliver on their responsibilities to commission healthcare services that meet the needs of their local populations and to expand mental health services in line with the aims of the Long Term Plan and the NHS Mental Health Implementation Plan 2019/20 – 2023/24², which provides the framework for local delivery.” Source location Response from department of Health and Social Care
Open published response
6 Aug 2022 Ernest Bacon · Prevention of Future Deaths report Manchester South
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Concerns raised 9 Failure to review relevant clinical notes during assessment View source Failure to flag sepsis concerns in patient notes View source Failure to escalate non-compliance with the sepsis policy View source Failure to provide face-to-face clinical review View source Insufficient availability of doctors for ward clinical reviews View source Delays in further clinical review after continued sepsis triggers View source Failure to recognise the seriousness of a patient's condition View source Failure to place sepsis-triggering patients on the sepsis pathway View source Failure to flag deteriorating patients during handover View source See 6 more concerns
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AI-generated summary
Ernest Bacon · 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
Ernest Thomas Bacon suffered an accidental fall at home, sustained a fractured neck of femur, and was admitted to Tameside General Hospital, where he subsequently had an ischaemic stroke. After triggering for sepsis on 16 January 2022, he was not reviewed face to face, the sepsis pathway was not followed, intravenous antibiotics were delayed, and the failure to escalate was not recognised. He died from sepsis at the hospital on 17 January 2022.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to review relevant clinical notes during assessment
Wider context from the report “2. As a consequence of the availability of doctors he was not reviewed face to face but via telephone. His notes were not seen . The seriousness of his condition was not recognised and he was not flagged up on handover;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 flag sepsis concerns in patient notes
Wider context from the report “4. The nursing team recognised that he was triggering for Sepsis but the notes were not flagged and the failure to follow the Sepsis policy was not escalated in accordance with Trust Policy. The reason for non-escalation was unclear.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 non-compliance with the sepsis policy
Wider context from the report “4. The nursing team recognised that he was triggering for Sepsis but the notes were not flagged and the failure to follow the Sepsis policy was not escalated in accordance with Trust Policy . The reason for non-escalation was unclear.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 face-to-face clinical review
Wider context from the report “2. As a consequence of the availability of doctors he was not reviewed face to face but via telephone . His notes were not seen. The seriousness of his condition was not recognised and he was not flagged up on handover;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of doctors for ward clinical reviews
Wider context from the report “1. The Inquest heard that when Mr Bacon became unwell on 16th January the Trust was staffed at weekend/OOD doctor numbers . This meant that there were a very limited number of doctors available within the hospital when the ward staff asked for a clinical review when Mr Bacon triggered for sepsis on the NEWS2 system. The Inquest heard that the staffing numbers of doctors and reliance on junior doctors at weekend to cover the wards is part of the national staffing model;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 further clinical review after continued sepsis triggers
Wider context from the report “3. The Trust Policy required he be treated for Sepsis. However he was not placed on the Sepsis pathway and a further review did not take place until a further doctor was asked to examine him at about 22.30 despite his NEWS2 score continuing to trigger for Sepsis ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the seriousness of a patient's condition
Wider context from the report “2. As a consequence of the availability of doctors he was not reviewed face to face but via telephone. His notes were not seen. The seriousness of his condition was not recognised and he was not flagged up on handover;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 place sepsis-triggering patients on the sepsis pathway
Wider context from the report “3. The Trust Policy required he be treated for Sepsis. However he was not placed on the Sepsis pathway and a further review did not take place until a further doctor was asked to examine him at about 22.30 despite his NEWS2 score continuing to trigger for Sepsis;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 flag deteriorating patients during handover
Wider context from the report “2. As a consequence of the availability of doctors he was not reviewed face to face but via telephone. His notes were not seen. The seriousness of his condition was not recognised and he was not flagged up on handover ;
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with AoMRC and NICE to consider how healthcare professionals will be educated and informed about updated national sepsis guidance.
Verbatim wording from the response “Additionally, the National Institute for Health and Care Excellence (NICE) has launched a consultation on updating the NG51 guideline for sepsis, based on the Academy of Medical Royal Colleges’ statement. The consultation will run from 7 to 21 December and can be reached on NICE’s website. As updated national sepsis guidance is implemented, the Department along with NHS England will continue to work closely with AoMRC and NICE to consider how healthcare professionals, including nurses and community health workers, will be educated and informed on its use. The Department will also continue to work closely with colleagues in the National Institute for Health and Care Research to understand, where appropriate, evidence and evaluation that can be commissioned to support best practice implementation of new guidance that is complemented by useful educational tools and awareness interventions.” Source location Response from Department of Health and Social Care
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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 workforce plan containing independently verified 10- and 15-year forecasts for doctors, nurses and other professionals.
Verbatim wording from the response “Finally, the Government has committed to publishing the workforce plan next year and this will include independently verified forecasts for the number of doctors, nurses and other professionals that will be needed in future, for 10- and 15-years’ time, taking full account of improvements in retention and productivity. This plan will help ensure that we have the right numbers of staff, with the right skills to transform and deliver high quality services fit for the future.” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Temporarily lift the cap on English medical school places for eligible students with 2020 or 2021 A-Level offers.
Verbatim wording from the response “In addition, the Government has funded 1,500 more medical school places each year for domestic students in England, which is a 25% increase over three years. This expansion was completed in September 2020 and has delivered over three new medical schools in England. We have seen the first graduates from this expansion enter foundation training in August 2022. Additionally, the Government temporarily lifted the cap on medical school places for students who completed A-Levels in 2020 and in 2021 and who had an offer from a university in” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with the National Institute for Health and Care Research to understand evidence and evaluation that may support implementation of new sepsis guidance.
Verbatim wording from the response “Additionally, the National Institute for Health and Care Excellence (NICE) has launched a consultation on updating the NG51 guideline for sepsis, based on the Academy of Medical Royal Colleges’ statement. The consultation will run from 7 to 21 December and can be reached on NICE’s website. As updated national sepsis guidance is implemented, the Department along with NHS England will continue to work closely with AoMRC and NICE to consider how healthcare professionals, including nurses and community health workers, will be educated and informed on its use. The Department will also continue to work closely with colleagues in the National Institute for Health and Care Research to understand, where appropriate, evidence and evaluation that can be commissioned to support best practice implementation of new guidance that is complemented by useful educational tools and awareness interventions.” Source location Response from Department of Health and Social Care
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fund 1,500 additional annual medical school places for domestic students in England, completing the expansion in September 2020.
Verbatim wording from the response “In addition, the Government has funded 1,500 more medical school places each year for domestic students in England, which is a 25% increase over three years. This expansion was completed in September 2020 and has delivered over three new medical schools in England. We have seen the first graduates from this expansion enter foundation training in August 2022. Additionally, the Government temporarily lifted the cap on medical school places for students who completed A-Levels in 2020 and in 2021 and who had an offer from a university in” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission NHS England to develop a 15-year NHS workforce plan addressing staffing numbers, skills, supply gaps and retention.
Verbatim wording from the response “With regard to concerns regarding the NHS workforce, the Department has commissioned NHS England to develop a long-term plan for the NHS workforce for the next 15 years. This high-level long-term workforce plan will look at the mix and number of staff required across all parts of the country and will set out the actions and reforms that will be needed to reduce supply gaps and improve retention.” Source location Response from Department of Health and Social Care
Open published response
4 Aug 2022 Margaret Ena Warwick · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Shortage of theatre capacity causing delays to surgery View source Shortage of HDU beds causing delays to care View source Insufficient cardiology capacity and out-of-hours cover for timely assessment 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
Margaret Ena Warwick · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Margaret Ena Warwick, who had significant ischaemic heart disease and left ventricular dysfunction, suffered an accidental fall at home on 23 February 2022 and was taken to hospital with a fractured neck of femur requiring surgery. Her pre-operative cardiac review, surgery and access to a high-dependency unit bed were delayed by shortages of cardiology cover, theatre capacity and HDU beds. She initially recovered after surgery but deteriorated and died in hospital on 7 March 2022.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Shortage of theatre capacity causing delays to surgery
Wider context from the report “2. Even after the assessment the Inquest heard evidence that there was a further delay due to a shortage of theatre capacity at the Trust .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Shortage of HDU beds causing delays to care
Wider context from the report “3. The delay was further compounded by a shortage of HDU beds at the Trust. The Inquest heard that the Trust was trying to manage this but this shortage was part of a national shortage of HDU beds.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 cardiology capacity and out-of-hours cover for timely assessment
Wider context from the report “1. The Inquest heard that under the NICE guidance where a patient needs an operation for a hip fracture such as in Mrs Warwick’s case and needs optimising, that optimisation should be dealt with expeditiously. In Mrs Warwick’s case she needed cardiology assessment. That delay was due in part to a shortage of cardiologists at the trust exacerbated in particular by a lack of cover by cardiologists over weekends and OOH. The Inquest heard that there was no facility for a patient such as Mrs Warwick to be assessed by cardiology over the weekend ;
” Open source report
4 Aug 2022 Malcolm John Garrett · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of specific guidance for expediting discharge and considering alternative treatment methods for high-risk patients View source Lack of specific guidance for managing immunosuppressed patients at high risk of Covid-19 in acute hospitals View source Insufficient monitoring of kidney function to prevent opiate toxicity 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
Malcolm John Garrett · 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
Malcolm John Garrett, who was immunosuppressed following a bilateral lung transplant, was admitted with severe back pain and subsequently developed pneumonia and Covid-19 while an inpatient. He deteriorated and died at Stepping Hill Hospital on 23 September 2021; post-mortem examination identified Covid pneumonitis and pseudomonas aeruginosa bronchopneumonia as the direct causes of death. Concerns included the absence of specific guidance for managing high-risk immunosuppressed patients, expediting their discharge or using alternative treatment methods, and monitoring kidney function to reduce opiate toxicity.
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 specific guidance for expediting discharge and considering alternative treatment methods for high-risk patients
Wider context from the report “2. The evidence before the inquest was that Mr Garratt needed to be discharged as quickly as possible to reduce the risk of acquiring Covid-19. However there was no specific guidance about expediting patients such as him and looking at alternative methods of treatment ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of specific guidance for managing immunosuppressed patients at high risk of Covid-19 in acute hospitals
Wider context from the report “1. The Inquest heard that it was recognised that Mr Garrett was at high risk of acquiring Covid-19 in a hospital setting as he was immunosuppressed following his transplant. Despite the risk being recognised he still acquired Covid-19. The Inquest heard that all such patients are at high risk in an acute hospital setting but there is no specific guidance for their management ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 monitoring of kidney function to prevent opiate toxicity
Wider context from the report “3. His discharge was delayed in part due to opiate toxicity. That arose as a consequence of his kidneys not functioning correctly. The inquest heard evidence that to avoid opiate toxicity is such situations there needs to be a greater use of and understanding of the importance of monitoring kidney function .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust's existing vulnerable-patient risk-management process, shared learning and discharge focus were considered sufficient responsive arrangements.
Verbatim wording from the response “NHS England also engaged with the Trust and advised that the Trust has a process in place to manage and reduce the risks of patients in vulnerable groups. They further advised that the Trust has shared the learning from this incident and that it has continued to focus on patient discharge.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CQC considered Trust assurances and ongoing monitoring sufficient, so it identified no need for further investigation of this specific case.
Verbatim wording from the response “The CQC advised that the matters of concern in this case, namely, hospital acquired COVID-19 and deaths attributed to a failure in monitoring kidney function are subject to regular reporting and/or evaluation as part of CQC’s monitoring and engagement activity. A management review meeting held in August 2022 concluded that neither concern was reflected in the monitoring data CQC held in relation to this Trust, such as being an outlier for the management of kidney injury. The Trust was asked at the time to provide any records or investigation reports relating to the death which the CQC would consider as part of its ongoing monitoring and engagement to ensure patients receive safe care and treatment.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing NHS, NICE and UKHSA guidance was considered sufficient to address COVID-19 infection prevention and expedited discharge concerns.
Verbatim wording from the response “You may wish to note that during the COVID-19 pandemic, extensive clinical guidance was issued by the NHS (eg. Coronavirus (england.nhs.uk) as well as by the National Institute for Health and Care Excellence (NICE), see Overview | COVID-19 rapid guideline: managing COVID-19 | Guidance | NICE. More broadly, UKHSA also issued guidance in relation to patient discharge and infection prevention and control in health and care settings.¹” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing BNF guidance on prescribing in renal impairment was considered sufficient to address opioid toxicity and kidney-function monitoring concerns.
Verbatim wording from the response “With regard to the issue relating to opiate toxicity and the need to understand the importance of monitoring kidney function. There is general guidance in the British National Formulary (BNF) in terms of ‘Prescribing in renal impairment’ and every opiate listed in the BNF will have an entry in relation to renal impairment eg codeine and morphine that state “Avoid use or reduce dose; opioid effects increased and prolonged or increased cerebral sensitivity occurs”.” Source location Response from Department of Health and Social Care
Open published response
4 Aug 2022 Stanislav Mucha · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Lack of documented agreement on assessment outcomes between professionals View source Failure to make and retain assessment notes 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
Stanislav Mucha · 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
Stanislav Mucha, aged 17, died after jumping from a height at the Rock centre in Bury, sustaining catastrophic injuries. The report raised concerns about the lack of notes from an independent psychiatrist and the absence of documented agreement between professionals about the outcome of a mental health assessment and the actions required.
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 documented agreement on assessment outcomes between professionals
Wider context from the report “2. Following the assessment on the 22nd January 2021 there was no documented agreement as to the outcome of the assessment between all professionals . This would have negated the confusion and lack of understanding as to what had occurred and the actions required.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to make and retain assessment notes
Wider context from the report “1. The Independent Section 12 Consultant Psychiatrist did not make and the court heard does not have the facilities to make any notes in relation to their assessment .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider including a specific timeframe for producing assessment notes in the revised Mental Health Act Code of Practice.
Verbatim wording from the response “The Code of Practice does not state the timeframes in which notes of any assessment should be produced and made available. As you may be aware, work is currently in train to reform the Mental Health Act and subsequently its Code of Practice. As part of these reforms we will consider whether the revised Code of Practice should include a specific time period during which notes of any assessment should be produced. I am therefore very grateful that you have brought this matter to my attention.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Section 12 doctors are responsible for recording their decisions when a Mental Health Act assessment has taken place.
Verbatim wording from the response “In addition, Section 14.75 of the Code of Practice places a responsibility on Section 12 doctors to record their decisions if an assessment has taken place. However, the Code of Practice is not explicit on how these notes should be recorded. We note that there was some dispute about whether an assessment had taken place.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation AMHPs are responsible for recording assessment outcomes and communicating decisions and reasons to relevant professionals.
Verbatim wording from the response “The Mental Health Act 1983 Code of Practice explicitly places the duty to record the outcome of an assessment on the Approved Mental Health Professional (AMHP). If the AMHP believed that an assessment had taken place, this should have been recorded and communicated to the Section 12 doctors. Relevant sections of the Code of Practice are below:” Source location Response from Department of Health and Social Care
Open published response
4 Aug 2022 Malcolm John Garrett · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Insufficient monitoring of kidney function to avoid opiate toxicity View source Lack of specific guidance for managing immunosuppressed high-risk patients in acute hospital settings View source Lack of specific guidance for expediting discharge of patients at high risk of acquiring Covid-19 View source Lack of specific guidance for considering alternative methods of treatment for patients at high risk of acquiring Covid-19 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
Malcolm John Garrett · 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
Malcolm John Garrett, who was immunosuppressed following a bilateral lung transplant, was admitted with a vertebral fracture and subsequently developed pneumonia and other complications. He acquired Covid-19 while an inpatient and died at Stepping Hill Hospital on 23 September 2021; the direct causes were Covid pneumonitis and pseudomonas aeruginosa bronchopneumonia. The concerns included the absence of specific guidance for managing high-risk immunosuppressed patients, expediting discharge or using alternative treatment methods, and monitoring kidney function to avoid opiate toxicity.
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 monitoring of kidney function to avoid opiate toxicity
Wider context from the report “3. His discharge was delayed in part due to opiate toxicity. That arose as a consequence of his kidneys not functioning correctly. The inquest heard evidence that to avoid opiate toxicity is such situations there needs to be a greater use of and understanding of the importance of monitoring kidney function .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 specific guidance for managing immunosuppressed high-risk patients in acute hospital settings
Wider context from the report “1. The Inquest heard that it was recognised that Mr Garrett was at high risk of acquiring Covid-19 in a hospital setting as he was immunosuppressed following his transplant. Despite the risk being recognised he still acquired Covid-19. The Inquest heard that all such patients are at high risk in an acute hospital setting but there is no specific guidance for their management ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 specific guidance for expediting discharge of patients at high risk of acquiring Covid-19
Wider context from the report “2. The evidence before the inquest was that Mr Garratt needed to be discharged as quickly as possible to reduce the risk of acquiring Covid-19. However there was no specific guidance about expediting patients such as him and looking at alternative methods of treatment;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of specific guidance for considering alternative methods of treatment for patients at high risk of acquiring Covid-19
Wider context from the report “2. The evidence before the inquest was that Mr Garratt needed to be discharged as quickly as possible to reduce the risk of acquiring Covid-19. However there was no specific guidance about expediting patients such as him and looking at alternative methods of treatment ;
” Open source report
21 Jul 2022 Gaia Kima Pope-Sutherland · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 12 Failure of Mental Health teams to provide assessment information directly to GPs View source Lack of policy for handling sexual harassment or assault in DHUFT inpatient units View source Lack of police officer knowledge of life-threatening illnesses and their behavioural impact View source Failure to flag key information on DHUFT RiO records View source Ambiguity in Dorset Police policies for welfare concerns, missing persons, and call handling, grading and deployment View source Lack of DHUFT policy for contact with patients’ families View source Failure to create, complete and store Dorset Police records appropriately View source Delay in AMHP feedback of Mental Health Act assessment information to GPs View source Lack of staff knowledge of Dorset Police welfare, missing persons, and call handling policies View source Lack of resourcing of epilepsy services View source Ambiguity and inconsistency in access to Community Mental Health care processes View source Lack of communication between neurology and psychiatric teams View source See 9 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
Gaia Kima Pope-Sutherland · 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
Gaia Kima Pope-Sutherland, who had epilepsy and mental health conditions, left her aunt’s address in a psychotic state on 7 November 2017 and was later found deceased on 18 November 2017. The jury concluded that she probably died from hypothermia between 15.59 on 7 November and 10.00 on 8 November 2017. Principal concerns included under-resourcing and poor communication between epilepsy, neurology and mental health services, as well as issues concerning police training, missing-person policies and record keeping, and communication and information sharing within mental health services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of Mental Health teams to provide assessment information directly to GPs
Wider context from the report “x. As per paragraph 1(xiii) above, when a Mental Health Act assessment is undertaken, there is a possibility that information may not be fed back to the GP in the best way or in a timely manner, if it is not fed back by those from the Mental Health team, and I therefore request that consideration is given to the DHUFT representatives forwarding information, directly to the GP, rather than through the discharging team at the acute hospital . This may include their RiO record notes, or their assessment notes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 policy for handling sexual harassment or assault in DHUFT inpatient units
Wider context from the report “vi. As per paragraph 1(ix) above, the occurrence of sexual harassment or assault whilst an inpatient at one of DHUFT’s inpatient units could have a detrimental effect on a person’s mental health which could have fatal consequences. I request that consideration is given to a policy being put into place to provide guidance to staff as to how to deal with this situation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of police officer knowledge of life-threatening illnesses and their behavioural impact
Wider context from the report “iii. As per paragraph 1(iv) above, there could be future deaths due to the lack of knowledge Police Officers in England and Wales have around life threatening illnesses , such as epilepsy and mental health illness, and I request that consideration is given by the College of Policing to providing national training to all staff across all police forces, on illnesses such as epilepsy and mental health illness, and the impact they have on individuals and their behaviour. I also request consideration to be given to these topics forming part of the syllabus for the College of Policing induction training for Police Officers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to flag key information on DHUFT RiO records
Wider context from the report “viii. As per paragraph 1(xi) above, information could be lost on lengthy RiO records held by DHUFT if there is a significant number of records, and I therefore request that consideration is given to a guidance document dealing with how and what information should be flagged on RiO which could be provided to all staff at DHUFT. I would further request consideration is given to training staff how to record information, so it is flagged on the record.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in Dorset Police policies for welfare concerns, missing persons, and call handling, grading and deployment
Wider context from the report “iv. As per paragraphs 1(v-vi) above, there could be future deaths that occur as a result of current Dorset Police policies around concern for welfare reports, missing persons reports, and the call handling, grading and deployment of resources and I request that consideration is given to a thorough review of these policies to reduce ambiguity and prevent future deaths. I would further request that consideration is given to providing a comprehensive training package to all Police Officers and control room staff within Dorset Police, around the missing persons policy, concern for welfare policy, and for control room staff only, the call handling, grading and deployment 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 Lack of DHUFT policy for contact with patients’ families
Wider context from the report “vii. As per paragraph 1(x) above, there is no specific policy in place within DHUFT around how to engage with the family or dealing with the Think Family approach. A lack of contact with family members , who know the patient best, could lead to information gaps, which could lead to future deaths. I request that consideration is given to a policy being created around contact both to, and from, a patient’s family.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to create, complete and store Dorset Police records appropriately
Wider context from the report “v. As per paragraphs 1(vii-viii) above, there is currently a risk that Dorset Police records are not being created, completed or stored in an appropriate way . This could result in a lack of detail, or incorrect information being recorded and relied upon , which could lead to a future death. I therefore request that consideration is given to reviewing how all Dorset Police records are held, to ensure integrity of the information, and that consideration is given to providing a training session on record keeping for all Dorset Police staff, across all areas of the Force.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delay in AMHP feedback of Mental Health Act assessment information to GPs
Wider context from the report “xi. As per paragraph 1(xiv) above, in respect of the feeding back of information to the GP by the AMHP which is detailed at paragraph 2.10 of Standard Operating Procedure for the flow of information following Mental Health Act assessments, I would request that consideration is given by Dorset County Council, BCP Council and DHUFT to reducing this timeframe from 7 days to 72 hours . Although this is a decision for Dorset County Council and BCP Council, the document is a DHUFT document and so will require their consideration too.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 staff knowledge of Dorset Police welfare, missing persons, and call handling policies
Wider context from the report “iv. As per paragraphs 1(v-vi) above, there could be future deaths that occur as a result of current Dorset Police policies around concern for welfare reports, missing persons reports, and the call handling, grading and deployment of resources and I request that consideration is given to a thorough review of these policies to reduce ambiguity and prevent future deaths. I would further request that consideration is given to providing a comprehensive training package to all Police Officers and control room staff within Dorset Police, around the missing persons policy, concern for welfare policy , and for control room staff only, the call handling, grading and deployment 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 Lack of resourcing of epilepsy services
Wider context from the report “i. As per paragraphs 1(i-iii) above, there could be future deaths locally and across the country due to the lack of resourcing of epilepsy services . I request consideration is given to a review of the nursing resources in epilepsy care locally in Dorset Epilepsy Service, and generally nationally across England and Wales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Ambiguity and inconsistency in access to Community Mental Health care processes
Wider context from the report “ix. As per paragraph 1(xii) above, I would request that consideration is given to providing training to all staff on the access to Community Mental Health services which could also cover the processes regarding discharge planning from the care of the mental health teams.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 communication between neurology and psychiatric teams
Wider context from the report “ii. Further I am concerned that there could be future deaths as a result of the lack of communication between neurology and psychiatric teams and request that there is consideration as to how to ensure effective lines of communication between the 2 disciplines.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing national training, professional development and clinical guidance arrangements are relied upon to support community mental health practice and discharge planning.
Verbatim wording from the response “With regard to your concerns related to the availability of training on access to community mental health services, including discharge planning – you may wish to note that NHSE provides funding and resources for continuous professional development for community mental health practice, together with supporting good care in all settings. HEE, working in partnership, also provides a range of quality training and resources for health care professionals, at all stages of their career; this is intended to support good practice. The training and resources provided by HEE align with policy direction and legislative frameworks, together with national clinical guidance such as that published by NICE (Transition between inpatient mental health settings and community or care home settings^5), which acknowledges its starting point.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust’s discharge-information procedure and statutory Mental Health Act guidance are relied upon to address communication after mental health assessments.
Verbatim wording from the response “With regard to Ms Pope-Sutherland’s discharge from hospital, my officials have informed me that the Trust has introduced a Standard Operating Procedure in May 2022, which covers the provision of information following Mental Health Act assessments. In addition, the” Source location Response from Department of Health and Social Care
Open published response
18 Jul 2022 Mr Graham Edgar White · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Lack of a registry of patients fitted with stents for monitoring and recall View source Failure to identify and escalate deaths through governance procedures as serious incidents for investigation View source Failure to assess whether patients with stents inserted prior to May 22 are at risk of similar deterioration 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
Mr Graham Edgar White · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Graham Edgar White was treated for a ureteric stone in November 2019 with an antegrade ureteric stent intended for temporary use. The stent remained in place for 20 months despite deterioration observed on multiple occasions, and was removed after he developed a urinary tract infection and right perinephric abscess. He developed sepsis and died in hospital on 18 August 2021. Concerns included the absence of a stent registry for monitoring and recall, uncertainty about other patients at risk, and delayed identification of the death as a serious incident.
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 registry of patients fitted with stents for monitoring and recall
Wider context from the report “1. Trust did not have in place a registry of those fitted with stents that would facilitate monitoring and recall of 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 Failure to identify and escalate deaths through governance procedures as serious incidents for investigation
Wider context from the report “3. The Trust did not successfully identify and escalate this death through its governance procedures as a serious incident for investigation until the issue was raised by the Coroner .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 whether patients with stents inserted prior to May 22 are at risk of similar deterioration
Wider context from the report “2. At the time of the inquest the Trust are unable to assess whether they have patients with stents inserted prior to May 22 who are at risk of a similar deterioration .
” Open source report
17 Jul 2022 James John Jude Booth · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to complete and transfer adverse-event information through shift handovers View source Lack of national guidance on perimeter fencing and security for outside areas of mental health locked wards View source Failure to maintain a safe and secure garden perimeter for vulnerable patients View source Failure to audit and robustly review handover documents View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
James John Jude Booth · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Booth, who had longstanding mental ill-health and was detained at The Priory, Altrincham, absconded on 7 October 2020 and was found dead on 14 October 2020; the medical cause of death was hanging. The principal concerns were inadequate security of the ward garden, including the fence, inadequate risk assessments, and failures to communicate and document repeated incidents and emerging risk between shifts.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and transfer adverse-event information through shift handovers
Wider context from the report “Matter Two
The evidence showed that there was no appreciation of the emerging pattern of behaviour. A major contributing factor was the lack of exchange and transfer of information at the handover between the consecutive shifts . In particular, the form specifically designed for this with a section for completion – ‘incidents in last 7 days’ which would have provided an information flow through was not completed .
Whilst I heard evidence of steps taken to improve information exchange at a higher level than between ward staff (nurses and HCAs) I was very surprised to hear that no audit of these ‘handover documents’ had been carried out. Given the fundamental importance of the exchange of information between each shift and consecutive shifts I am of the opinion that The Priory have not carried out a sufficiently robust review. Until this failure is addressed there is a significant risk of a breakdown in the communication of adverse events across the shift pattern of several days . The risk of a lack of appreciation of an emerging pattern of behaviour remains.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on perimeter fencing and security for outside areas of mental health locked wards
Wider context from the report “Matter One
The inquest heard that the Priory had identified that the garden fence was a risk, in particular the section over the door, in about December 2019. There had been a number of escapes both over the fence and through it, in the months leading up to James’ escape. The number of escapes indicates that garden area was not safe. There was a plan to replace it but there were other priorities.
More striking was that there is no national guidance for perimeter fencing and security for the outside areas of mental health ‘locked wards’ ; unlike that in existence for mental health ‘secure units’. In particular, the height of the fence .
While it is accepted that national guidance ought not be necessary to carry out appropriate risk assessments and ensure secure/safe spaces it is clear that such guidance is necessary to ensure the correct level of security for vulnerable patients , whilst benefitting from the therapeutic setting of an outdoor space.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 safe and secure garden perimeter for vulnerable patients
Wider context from the report “Matter One
The inquest heard that the Priory had identified that the garden fence was a risk , in particular the section over the door, in about December 2019. There had been a number of escapes both over the fence and through it , in the months leading up to James’ escape. The number of escapes indicates that garden area was not safe . There was a plan to replace it but there were other priorities.
More striking was that there is no national guidance for perimeter fencing and security for the outside areas of mental health ‘locked wards’; unlike that in existence for mental health ‘secure units’. In particular, the height of the fence.
While it is accepted that national guidance ought not be necessary to carry out appropriate risk assessments and ensure secure/safe spaces it is clear that such guidance is necessary to ensure the correct level of security for vulnerable patients, whilst benefitting from the therapeutic setting of an outdoor space.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 audit and robustly review handover documents
Wider context from the report “Matter Two
The evidence showed that there was no appreciation of the emerging pattern of behaviour. A major contributing factor was the lack of exchange and transfer of information at the handover between the consecutive shifts. In particular, the form specifically designed for this with a section for completion – ‘incidents in last 7 days’ which would have provided an information flow through was not completed.
Whilst I heard evidence of steps taken to improve information exchange at a higher level than between ward staff (nurses and HCAs) I was very surprised to hear that no audit of these ‘handover documents’ had been carried out . Given the fundamental importance of the exchange of information between each shift and consecutive shifts I am of the opinion that The Priory have not carried out a sufficiently robust review . Until this failure is addressed there is a significant risk of a breakdown in the communication of adverse events across the shift pattern of several days. The risk of a lack of appreciation of an emerging pattern of behaviour remains.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with stakeholders to expand evidence on physical barriers and explore approaches to reduce absconding risk.
Verbatim wording from the response “Turning to perimeter fence/wall height and its role in patient safety, I understand that the Department received a Prevention of Future Death report last year from another coroner, who raised similar concerns. In response to this, officials worked with a range of stakeholders, including NCISH, to explore expanding the evidence base around the role those physical barriers play in patient safety and from this explore approaches to reducing the risk of such absconding. NCISH has updated its patient suicide questionnaire to include information about whether a patient who has died by suicide was able to leave the ward by scaling a physical barrier – a perimeter fence is provided as an example.” 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 Current guidance does not prescribe acute-ward fence heights; appropriate security measures are determined by the service location and layout.
Verbatim wording from the response “With regard to guidance, acute mental health wards, such as Priory Altrincham, are the least restrictive of inpatient mental health settings. They accommodate voluntary patients as well as people detained under section of the Mental Health Act, and therefore current guidance in Health Building Note 03-01: Adult acute mental health units¹ (HBN 03-01), whilst mute on the specifics of fence height, states that:” Source location Response from Department of Health and Social Care
Open published response
17 Jul 2022 Rebecca Jayne Flint · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Reliance on individual Care Coordinator capacity for comprehensive mental-health information View source Unavailability of alternative Care Coordinator cover during staff absence View source Lack of consistency in Care Coordinator job descriptions and role requirements 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
Rebecca Jayne Flint · 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
Rebecca Flint was under the care of the Trafford Community Mental Health Team and was found at home on 7 September 2020. The report raised concerns about inconsistent Care Coordinator roles between Trusts and limited Community Mental Health Team resources, including the absence of cover when a Care Coordinator was unavailable.
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 Reliance on individual Care Coordinator capacity for comprehensive mental-health information
Wider context from the report “From the evidence I heard, the Care Coordinator’s role is to assess the patient’s care needs and to plan and review those needs across the broad spectrum of physical and mental health and social needs within the multi-disciplinary team within the Mental Health Trust.
The Care Coordinator is the individual who has the closest contact with the patient and, as the title suggests, is the liaison link for every other professional and agency. From the evidence, it is clear that an enormous burden of responsibility and reliance is placed on the individual Care Coordinator as they are expected to be the conduit of information to other professionals and to continuously review and assess all areas of the patient’s needs and to call in others as required.
I concluded that the only person who had the ability to have a comprehensive view of Ms Flint’s mental health was the Care Coordinator and the quality of the information provided to others within the multi-disciplinary team and other agencies was entirely dependent on the ability, availability, resources, experience, training and skills of the Care Coordinator .
(1) From the evidence, it appeared that the precise job description and requirements of Care coordinators differs between local Trusts so that there is no consistency as to the way in which individual Care coordinators are expected to fulfil their role.
(2) It also emerged that the resources available to the Community Mental Health Teams are limited so that in the absence of a Care Coordinator during periods of annual leave or sickness, there was no other Care Coordinator who could fulfil the role.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 alternative Care Coordinator cover during staff absence
Wider context from the report “From the evidence I heard, the Care Coordinator’s role is to assess the patient’s care needs and to plan and review those needs across the broad spectrum of physical and mental health and social needs within the multi-disciplinary team within the Mental Health Trust.
The Care Coordinator is the individual who has the closest contact with the patient and, as the title suggests, is the liaison link for every other professional and agency. From the evidence, it is clear that an enormous burden of responsibility and reliance is placed on the individual Care Coordinator as they are expected to be the conduit of information to other professionals and to continuously review and assess all areas of the patient’s needs and to call in others as required.
I concluded that the only person who had the ability to have a comprehensive view of Ms Flint’s mental health was the Care Coordinator and the quality of the information provided to others within the multi-disciplinary team and other agencies was entirely dependent on the ability, availability, resources, experience, training and skills of the Care Coordinator.
(1) From the evidence, it appeared that the precise job description and requirements of Care coordinators differs between local Trusts so that there is no consistency as to the way in which individual Care coordinators are expected to fulfil their role.
(2) It also emerged that the resources available to the Community Mental Health Teams are limited so that in the absence of a Care Coordinator during periods of annual leave or sickness, there was no other Care Coordinator who could fulfil the role .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 consistency in Care Coordinator job descriptions and role requirements
Wider context from the report “From the evidence I heard, the Care Coordinator’s role is to assess the patient’s care needs and to plan and review those needs across the broad spectrum of physical and mental health and social needs within the multi-disciplinary team within the Mental Health Trust.
The Care Coordinator is the individual who has the closest contact with the patient and, as the title suggests, is the liaison link for every other professional and agency. From the evidence, it is clear that an enormous burden of responsibility and reliance is placed on the individual Care Coordinator as they are expected to be the conduit of information to other professionals and to continuously review and assess all areas of the patient’s needs and to call in others as required.
I concluded that the only person who had the ability to have a comprehensive view of Ms Flint’s mental health was the Care Coordinator and the quality of the information provided to others within the multi-disciplinary team and other agencies was entirely dependent on the ability, availability, resources, experience, training and skills of the Care Coordinator.
(1) From the evidence, it appeared that the precise job description and requirements of Care coordinators differs between local Trusts so that there is no consistency as to the way in which individual Care coordinators are expected to fulfil their role .
(2) It also emerged that the resources available to the Community Mental Health Teams are limited so that in the absence of a Care Coordinator during periods of annual leave or sickness, there was no other Care Coordinator who could fulfil the role.
” Open source report
17 Jul 2022 Ronald Hartley · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Delays in ambulance attendance and transport for patients requiring hospital care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ronald Hartley · 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
Ronald Hartley fell in his garden, fractured his neck of femur, underwent surgery, became increasingly frail, and died in hospital on 22 November 2021. His family reported being told that an ambulance would take approximately six hours to attend, so they transported him to hospital themselves, causing him significant pain and discomfort.
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 ambulance attendance and transport for patients requiring hospital care
Wider context from the report “The evidence to the Inquest from the family was that when they found Mr Hartley and rang for an ambulance they were told that due to the ongoing demands on the Ambulance Service that it would be approximately 6 hours before one could attend and transport Mr Hartley to hospital . He had fallen in his garden in November. The family were faced with a choice of waiting with him for 6 hours when he clearly needed to be in hospital or transporting him to hospital themselves. Given his distress and their concerns about the impact of the prolonged wait on him they decided to transport him to hospital in their own vehicle. The Inquest was told that this was extremely difficult and caused significant pain and discomfort to Mr Hartley.
” 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 £20 million to upgrade the ambulance fleet.
Verbatim wording from the response “During this year NHS ambulance trusts have been supported with NHS England allocating £150 million of additional system funding for ambulance service pressures, supporting improvements to response times through additional call handler recruitment, retention, and other funding pressures. This is alongside £20 million to upgrade the ambulance fleet.” 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 significantly in the ambulance workforce and support workforce.
Verbatim wording from the response “The Government has also made significant investments in the ambulance workforce and the number of NHS ambulance staff and support staff has increased by over 40% since September 2010. Health Education England has a mandated target to train 3,000 paramedic graduates nationally per annum from 2021-2024, further increasing the domestic paramedic workforce to meet future demands on the service.” 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 £3.3 billion in each of 2023–24 and 2024–25 to improve urgent and emergency care performance.
Verbatim wording from the response “The government is committed to supporting the ambulance service to manage the pressures it is facing, ensuring that people receive the treatment that they need when they need it.” 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 Allocate £150 million in additional system funding to support ambulance-service pressures, including call-handler recruitment and retention.
Verbatim wording from the response “During this year NHS ambulance trusts have been supported with NHS England allocating £150 million of additional system funding for ambulance service pressures, supporting improvements to response times through additional call handler recruitment, retention, and other funding pressures. This is alongside £20 million to upgrade the ambulance fleet.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The NHS will set out detailed recovery plans to improve urgent and emergency care performance.
Verbatim wording from the response “This will be supported by the government investing an additional £3.3 billion in each of 2023-24 and 2024-25 as announced in the Autumn Statement. This will enable rapid action to improve urgent and emergency care performance towards pre-pandemic levels. The NHS will set out detailed recovery plans in the new year.” Source location Response from Department of Health and Social Care
Open published response
13 Jul 2022 Daniel Clements · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 2 Failure to provide coordinated continuing support for people with suicidal feelings without overt psychiatric illness View source Lack of a safe-care pathway for people displaying suicidal ideation without deemed mental illness 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
Daniel Clements · 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
Daniel Clements, aged 27, was taken to hospital by police for a psychiatric assessment on 19 July 2021 and was discharged to his GP after being deemed not to have a mental illness. Later that evening, he ran into the path of a fast-moving train and sustained fatal injuries. The principal concerns were how to keep people displaying suicidal ideation safe when they are not considered mentally ill, and whether agencies adequately supported Mr Clements, who was described as vulnerable and had experienced homelessness and difficulties accessing support and medication.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide coordinated continuing support for people with suicidal feelings without overt psychiatric illness
Wider context from the report “(4) Mr Clements was passed between agencies without any lasting benefit . This tragic situation illustrates the void in relation to those with suicidal feelings without any overt psychiatric illness .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 safe-care pathway for people displaying suicidal ideation without deemed mental illness
Wider context from the report “(1) How can a person displaying suicidal ideation be kept safe, if deemed not to be mentally ill?
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with NICE and suicide and self-harm prevention experts to further develop evidence-based best practice in safety planning and managing needs and risks.
Verbatim wording from the response “Further, in September 2022, the National Institute for Health and Care Excellence (NICE) published new guidance on the assessment, management and preventing recurrence of self-harm.¹ To support services to adhere to this guidance, and to enable a definitive change in clinical practice and culture, the Department and NHS England will work with NICE and experts in suicide and self-harm prevention to further develop evidence-based best practice in safety planning and the management of needs and risks. This work will be co-produced by experts with experience in the field and in line with evidenced based practice.” 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 For people below the detention threshold, crisis needs should be met through community partnerships between local authorities, NHS organisations and voluntary-sector organisations.
Verbatim wording from the response “Where individuals are not experiencing mental illness of a severity that makes detention under the Mental Health Act appropriate, their needs should be met in the community where partnership between Local Authorities, NHS organisations and Voluntary sector organisations is so critical. Local Authorities hold a range of duties under the Care Act 2014 to promote individual wellbeing, provide information and advice, safeguard adults from abuse and neglect as well as promote the integration of health and care services for those in need of care and support. The expansion of crisis services in the NHS Long Term Plan, backed up by £150m of additional capital funding for crisis centres, will support this aim alongside system partners.” Source location Response from Department of Health and Social Care
Open published response
7 Jul 2022 Seema Pravin HARIBHAI · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 12 Failure to advise immediate cessation of herbal remedies View source Failure to advise immediate attendance at a hospital emergency department View source Failure to identify prescribed drugs or drug combinations View source Failure to record relevant clinical history and symptoms View source Failure to recognise prescribed medicines as a possible cause of harm View source Lack of routine awareness of possible complications of Ayurvedic treatment View source Insufficient continuing professional development training for Ayurvedic practitioners View source Failure to arrange an in-person physical examination View source Lack of regulation of Ayurvedic practitioners View source Delay in responding to markedly abnormal blood test results View source Lack of quality control for medicines manufactured abroad View source Failure to advise immediate cessation of Ayurvedic medicines View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Seema Pravin HARIBHAI · 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
Seema Haribhai, who had increasingly disabling psoriatic arthritis, took herbal remedies prescribed by an Ayurvedic practitioner and developed liver failure, dying some weeks later. The investigation determined that she died as a consequence of the administration of Ayurvedic medicines intended to treat psoriatic arthritis. Concerns included the practitioner’s failure to recognise the possible harm from the medicines or advise their immediate cessation, the lack of regulation and evidence of quality control, and shortcomings in the GP’s assessment and response to her symptoms and abnormal blood test.
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 advise immediate cessation of herbal remedies
Wider context from the report “However, when she first discovered that her patient had developed a yellow discolouration, whilst she recognised that the liver was probably responsible, she did not recognise that the cause might be her own prescription. She did not advise the only course of action with the potential to save Seema Haribhai’s life: an immediate cessation of all the herbal remedies.
Even when she gave evidence in court, the Ayurvedic practitioner did not seem to canvass the possibility that the medicines she had prescribed could have caused harm. She had at one stage advised her patient to have a routine blood test, but she had not at any stage advised immediate attendance at a hospital emergency department.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to advise immediate attendance at a hospital emergency department
Wider context from the report “However, when she first discovered that her patient had developed a yellow discolouration, whilst she recognised that the liver was probably responsible, she did not recognise that the cause might be her own prescription. She did not advise the only course of action with the potential to save Seema Haribhai’s life: an immediate cessation of all the herbal remedies.
Even when she gave evidence in court, the Ayurvedic practitioner did not seem to canvass the possibility that the medicines she had prescribed could have caused harm. She had at one stage advised her patient to have a routine blood test, but she had not at any stage advised immediate attendance at a hospital emergency department .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to identify prescribed drugs or drug combinations
Wider context from the report “I am aware that one of the treating hepatologists from the Royal Free Hospital attempted to report this matter to the MHRA under the yellow card scheme, but was in some difficulty because he could not identify which drugs or drug combinations had been prescribed and had caused the liver injury.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to record relevant clinical history and symptoms
Wider context from the report “However, the GP did not record the detail of the history, he did not record exactly when the yellow discolouration first appeared, and he did not record the absence of any other signs and symptoms . He did not ask for attendance at the surgery so that he could perform a physical examination. He did not advise immediate cessation of the Ayurvedic medicines.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise prescribed medicines as a possible cause of harm
Wider context from the report “However, when she first discovered that her patient had developed a yellow discolouration, whilst she recognised that the liver was probably responsible, she did not recognise that the cause might be her own prescription . She did not advise the only course of action with the potential to save Seema Haribhai’s life: an immediate cessation of all the herbal remedies.
Even when she gave evidence in court, the Ayurvedic practitioner did not seem to canvass the possibility that the medicines she had prescribed could have caused harm. She had at one stage advised her patient to have a routine blood test, but she had not at any stage advised immediate attendance at a hospital emergency department.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of routine awareness of possible complications of Ayurvedic treatment
Wider context from the report “It appears from the evidence I heard in court that Ayurvedic practitioners do not necessarily have the possible complications of Ayurvedic treatment as part of their routine frame of reference . All medicines can cause harm, even those that are herbal based.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 continuing professional development training for Ayurvedic practitioners
Wider context from the report “I heard evidence at inquest that Ayurvedic practitioners are not in any way regulated. Even those who are members of the Ayurvedic Professionals Association receive as little as two hours of continuing professional development training per annum .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 arrange an in-person physical examination
Wider context from the report “However, the GP did not record the detail of the history, he did not record exactly when the yellow discolouration first appeared, and he did not record the absence of any other signs and symptoms. He did not ask for attendance at the surgery so that he could perform a physical examination . He did not advise immediate cessation of the Ayurvedic medicines.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of regulation of Ayurvedic practitioners
Wider context from the report “I heard evidence at inquest that Ayurvedic practitioners are not in any way regulated . Even those who are members of the Ayurvedic Professionals Association receive as little as two hours of continuing professional development training per annum.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delay in responding to markedly abnormal blood test results
Wider context from the report “The GP consultation was on 5 November, the blood test was conducted on 9 November, the results came back to the surgery on 10 and 11 November, and an appointment was booked for 15 November . Meanwhile, same day admission to hospital was arranged on 15 November solely because a nurse had noted the blood test result at a routine rheumatology appointment .
The blood test result was so abnormal that, even without examination, the consult rheumatologist saw no option but immediate admission .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 quality control for medicines manufactured abroad
Wider context from the report “The medicines prescribed by Ayurvedic practitioners are manufactured abroad. I did not hear evidence of any quality control .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to advise immediate cessation of Ayurvedic medicines
Wider context from the report “However, the GP did not record the detail of the history, he did not record exactly when the yellow discolouration first appeared, and he did not record the absence of any other signs and symptoms. He did not ask for attendance at the surgery so that he could perform a physical examination. He did not advise immediate cessation of the Ayurvedic medicines .
” Open source report
1 Jul 2022 Daniel Xavier · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Failure to account for learning disability when taking a clear clinical history View source Failure to provide effective referral communication and formal handover to the surgical team View source Failure to consider and act on dangerously elevated creatinine results before discharge View source Failure to review clinical records before accepting a surgical referral 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
Daniel Xavier · 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
Daniel Xavier attended the emergency department on 21 October 2021 with a history of painful haemorrhoids and an accompanying history of constipation. A venous blood gas showed an abnormally high creatinine level, but the result was not considered before he was discharged; he later became increasingly unwell, suffered a cardiac arrest, and could not be resuscitated. The report identified concerns about the failure to act on the blood result, a chaotic referral and inadequate handover, and insufficient consideration of his learning disability when taking his history.
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 account for learning disability when taking a clear clinical history
Wider context from the report “3. Due regard was not given to Mr Xavier’s learning disability during his admission on 21st October 2021. Insufficient time and care was taken to establish a clear history from the patient , most pertinently his 7-day history of constipation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide effective referral communication and formal handover to the surgical team
Wider context from the report “2. Mr Xavier’s referral to the surgical team by his GP was chaotic. No telephone contact was made between the GP and the on call surgical team. Mr Xavier was therefore triaged by a ED nurse and subsequently, a rapid assessment team junior doctor before he was brought to the attention of the surgical team. Despite these assessments, no formal handover was provided to the surgical team, setting out the extent of the history, clinical observations and diagnostic processes that had previously taken place . Despite these shortcomings, the surgical team accepted the referral without considering Mr Xavier’s clinical records beforehand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to consider and act on dangerously elevated creatinine results before discharge
Wider context from the report “1. Prior to Mr Xavier’s discharge from hospital on the evening of 21st October 2021, the deceased’s venous blood gas results were not considered and acted upon by staff . The results, available from 13.17, indicated that Mr Xavier had a dangerously elevated creatinine level . Evidence heard at inquest indicated that had the results been considered, Mr Xavier would not have been discharged, he would have been escalated to the resuscitation department. Further, the Trust accepted that had the creatinine levels been acted upon, it is likely that the outcome for Mr Xavier could have been different.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 review clinical records before accepting a surgical referral
Wider context from the report “2. Mr Xavier’s referral to the surgical team by his GP was chaotic. No telephone contact was made between the GP and the on call surgical team. Mr Xavier was therefore triaged by a ED nurse and subsequently, a rapid assessment team junior doctor before he was brought to the attention of the surgical team. Despite these assessments, no formal handover was provided to the surgical team, setting out the extent of the history, clinical observations and diagnostic processes that had previously taken place. Despite these shortcomings, the surgical team accepted the referral without considering Mr Xavier’s clinical records beforehand .
” 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 Carry out a public consultation on the Code of Practice for mandatory learning disability and autism training.
Verbatim wording from the response “Furthermore, the Secretary of State will publish a Code of Practice that will outline how to meet the new requirement for mandatory training including its content, delivery, ongoing monitoring and evaluation. The government will carry out a public consultation on the Code of Practice and timings for this consultation are currently being considered.” 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 the first e-learning component of Oliver McGowan Mandatory Training available.
Verbatim wording from the response “To support this new training requirement, the government have made significant progress on the Oliver McGowan Mandatory Training which was trialled in England during 2021 with over 8000 people. Part one of the training – an e-learning package – is now available.” 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 Require CQC-registered service providers to ensure employees receive role-appropriate learning disability and autism training.
Verbatim wording from the response “Introducing mandatory training is an important way in which we can address persistent disparities in health and care outcomes for people with a learning disability and autistic people as evidenced from LeDeR reports. That is why the Government have now introduced a requirement for CQC registered service providers to ensure their employees receive learning disability and autism training appropriate to their role, as set out in the Health and Care Act 2022, which came into force on 1 July 2022.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a Code of Practice covering mandatory training requirements, content, delivery, monitoring and evaluation.
Verbatim wording from the response “Furthermore, the Secretary of State will publish a Code of Practice that will outline how to meet the new requirement for mandatory training including its content, delivery, ongoing monitoring and evaluation. The government will carry out a public consultation on the Code of Practice and timings for this consultation are currently being considered.” Source location Response from Department of Health and Social Care
Open published response
29 Jun 2022 Paul Alexander Meadows · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 5 Unavailability of practitioners to answer received calls View source Insufficient practitioner time to gather information and conduct triage and risk assessment View source Lack of thorough risk assessment and safety planning View source Inconsistent judgement of triage scale View source Insufficient professional curiosity around risk and suicidal ideation View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Alexander Meadows · 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
Paul Alexander Meadows was found dead at home on 4 August 2021 after taking a Codeine overdose, against a background of physical health difficulties and deteriorating mental health. The report identified concerns that his mental health crisis was not recognised by the First Response Service on 3 August 2021 and that there was no onward referral for urgent or emergency intervention. It also identified broader concerns about the time available to practitioners to gather information and properly triage and risk assess callers, linked to workload and recruitment pressures.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of practitioners to answer received calls
Wider context from the report “The Norfolk & Suffolk NHS Foundation Trust accepted that there were broad issues in relation to thoroughness of risk assessment and safety planning in other cases as well as Paul’s case. There were inconsistencies in judgement of triage scale and the level of professional curiosity around risk and suicidal ideation.
It was accepted that, in Summer 2021, due to resource pressure – specifically, a discrepancy between the anticipated activity and the actual, significant, volume of callers, there were occasions when First Response Service practitioners did not have enough time to gather the required information and properly to triage and risk assess.
The evidence was that, although the position now varies considerably from day to day, due in particular to difficulties with vacancies it would be unfair to say that staff do not still feel pressured at times on calls.
The evidence was that the difficulties in recruitment are associated with differences in funding for the First Response Service between the commissioners for different counties. For example, there is a significant difference between the funding available to Norfolk and to Suffolk, despite both counties having a similar volume of calls.
The Commissioners are aware of the number of calls unanswered because of practitioners being unable to take the calls received and the matter remains one that is raised with the Commissioners on an ongoing basis and subject to ongoing negotiation.
Nevertheless, the Court has, to recap, received evidence that, given difficulties in recruitment arising out of the level of funding received by the First Response Service in Suffolk, it remains the position that practitioners do not always have sufficient time on calls to gather the required information and properly to triage and risk assess. Where, for these reasons, First Response practitioners are not able properly to triage and risk assess, this creates a risk of future deaths that will occur or will continue to exist in the future.
The evidence was also that this is not just a concern in one county, but one that is experienced nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient practitioner time to gather information and conduct triage and risk assessment
Wider context from the report “The Norfolk & Suffolk NHS Foundation Trust accepted that there were broad issues in relation to thoroughness of risk assessment and safety planning in other cases as well as Paul’s case. There were inconsistencies in judgement of triage scale and the level of professional curiosity around risk and suicidal ideation.
It was accepted that, in Summer 2021, due to resource pressure – specifically, a discrepancy between the anticipated activity and the actual, significant, volume of callers, there were occasions when First Response Service practitioners did not have enough time to gather the required information and properly to triage and risk assess .
The evidence was that, although the position now varies considerably from day to day, due in particular to difficulties with vacancies it would be unfair to say that staff do not still feel pressured at times on calls.
The evidence was that the difficulties in recruitment are associated with differences in funding for the First Response Service between the commissioners for different counties. For example, there is a significant difference between the funding available to Norfolk and to Suffolk, despite both counties having a similar volume of calls.
The Commissioners are aware of the number of calls unanswered because of practitioners being unable to take the calls received and the matter remains one that is raised with the Commissioners on an ongoing basis and subject to ongoing negotiation.
Nevertheless, the Court has, to recap, received evidence that, given difficulties in recruitment arising out of the level of funding received by the First Response Service in Suffolk, it remains the position that practitioners do not always have sufficient time on calls to gather the required information and properly to triage and risk assess . Where, for these reasons, First Response practitioners are not able properly to triage and risk assess, this creates a risk of future deaths that will occur or will continue to exist in the future.
The evidence was also that this is not just a concern in one county, but one that is experienced nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of thorough risk assessment and safety planning
Wider context from the report “The Norfolk & Suffolk NHS Foundation Trust accepted that there were broad issues in relation to thoroughness of risk assessment and safety planning in other cases as well as Paul’s case . There were inconsistencies in judgement of triage scale and the level of professional curiosity around risk and suicidal ideation.
It was accepted that, in Summer 2021, due to resource pressure – specifically, a discrepancy between the anticipated activity and the actual, significant, volume of callers, there were occasions when First Response Service practitioners did not have enough time to gather the required information and properly to triage and risk assess.
The evidence was that, although the position now varies considerably from day to day, due in particular to difficulties with vacancies it would be unfair to say that staff do not still feel pressured at times on calls.
The evidence was that the difficulties in recruitment are associated with differences in funding for the First Response Service between the commissioners for different counties. For example, there is a significant difference between the funding available to Norfolk and to Suffolk, despite both counties having a similar volume of calls.
The Commissioners are aware of the number of calls unanswered because of practitioners being unable to take the calls received and the matter remains one that is raised with the Commissioners on an ongoing basis and subject to ongoing negotiation.
Nevertheless, the Court has, to recap, received evidence that, given difficulties in recruitment arising out of the level of funding received by the First Response Service in Suffolk, it remains the position that practitioners do not always have sufficient time on calls to gather the required information and properly to triage and risk assess. Where, for these reasons, First Response practitioners are not able properly to triage and risk assess, this creates a risk of future deaths that will occur or will continue to exist in the future.
The evidence was also that this is not just a concern in one county, but one that is experienced nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistent judgement of triage scale
Wider context from the report “The Norfolk & Suffolk NHS Foundation Trust accepted that there were broad issues in relation to thoroughness of risk assessment and safety planning in other cases as well as Paul’s case. There were inconsistencies in judgement of triage scale and the level of professional curiosity around risk and suicidal ideation.
It was accepted that, in Summer 2021, due to resource pressure – specifically, a discrepancy between the anticipated activity and the actual, significant, volume of callers, there were occasions when First Response Service practitioners did not have enough time to gather the required information and properly to triage and risk assess.
The evidence was that, although the position now varies considerably from day to day, due in particular to difficulties with vacancies it would be unfair to say that staff do not still feel pressured at times on calls.
The evidence was that the difficulties in recruitment are associated with differences in funding for the First Response Service between the commissioners for different counties. For example, there is a significant difference between the funding available to Norfolk and to Suffolk, despite both counties having a similar volume of calls.
The Commissioners are aware of the number of calls unanswered because of practitioners being unable to take the calls received and the matter remains one that is raised with the Commissioners on an ongoing basis and subject to ongoing negotiation.
Nevertheless, the Court has, to recap, received evidence that, given difficulties in recruitment arising out of the level of funding received by the First Response Service in Suffolk, it remains the position that practitioners do not always have sufficient time on calls to gather the required information and properly to triage and risk assess. Where, for these reasons, First Response practitioners are not able properly to triage and risk assess, this creates a risk of future deaths that will occur or will continue to exist in the future.
The evidence was also that this is not just a concern in one county, but one that is experienced nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient professional curiosity around risk and suicidal ideation
Wider context from the report “The Norfolk & Suffolk NHS Foundation Trust accepted that there were broad issues in relation to thoroughness of risk assessment and safety planning in other cases as well as Paul’s case. There were inconsistencies in judgement of triage scale and the level of professional curiosity around risk and suicidal ideation .
It was accepted that, in Summer 2021, due to resource pressure – specifically, a discrepancy between the anticipated activity and the actual, significant, volume of callers, there were occasions when First Response Service practitioners did not have enough time to gather the required information and properly to triage and risk assess.
The evidence was that, although the position now varies considerably from day to day, due in particular to difficulties with vacancies it would be unfair to say that staff do not still feel pressured at times on calls.
The evidence was that the difficulties in recruitment are associated with differences in funding for the First Response Service between the commissioners for different counties. For example, there is a significant difference between the funding available to Norfolk and to Suffolk, despite both counties having a similar volume of calls.
The Commissioners are aware of the number of calls unanswered because of practitioners being unable to take the calls received and the matter remains one that is raised with the Commissioners on an ongoing basis and subject to ongoing negotiation.
Nevertheless, the Court has, to recap, received evidence that, given difficulties in recruitment arising out of the level of funding received by the First Response Service in Suffolk, it remains the position that practitioners do not always have sufficient time on calls to gather the required information and properly to triage and risk assess. Where, for these reasons, First Response practitioners are not able properly to triage and risk assess, this creates a risk of future deaths that will occur or will continue to exist in the future.
The evidence was also that this is not just a concern in one county, but one that is experienced nationally.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand and diversify the types of mental health workforce roles available.
Verbatim wording from the response “Turning to your matter of concern regarding staff vacancies, we are fully committed to attracting, training and recruiting the mental health workforce of the future. Through our plans set out in ‘Implementing the Five Year Forward View for Mental Health’ and ‘Stepping Forward to 2020/2021: The mental health workforce plan for England’, we have expanded and diversified the types of roles that are available.” 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 delivery of 24/7 urgent mental health helplines established during the pandemic.
Verbatim wording from the response “Additionally, in 2021/22 we provided £500 million to accelerate our expansion plans. Of this, £110 million was used to expand adult mental health services, including investment in crisis services and maintaining the delivery of the 24/7 urgent mental health helplines stood up during in the pandemic.” 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 £111 million in 2021/22 to grow the mental health workforce.
Verbatim wording from the response “The NHS Mental Health Implementation Plan 2019/20–2023/24 sets out the need for the mental health workforce to grow by over 27,000 during this time frame, to support the expansion and transformation of NHS mental health services and give an extra two million people the mental health support they need. We invested £111 million in 2021/22 to grow the mental health workforce to deliver these ambitious commitments. Further, Health Education England and NHS England have been working with Integrated Care Systems (ICSs) to confirm plans to 2024. The aim is for every ICS to look at everything they can do to meet the Implementation Plan ambition, including through innovative service models, increasing supply, and improving retention and recruitment.” 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 commissioners are responsible for deciding service provision and ensuring services meet local population needs.
Verbatim wording from the response “With regards to differences in funding available to Norfolk and to Suffolk, NHS England is responsible for determining allocations of financial resources to Integrated Care Boards from April 2022. The allocations process uses a statistical formula to make geographic distribution fair and objective, so that it more clearly reflects local healthcare need and helps to reduce health inequalities. Local commissioners are responsible for decisions about the provision of services in their area and ensuring that they meet the needs of the local population.” Source location Response from Department of Health and Social Care
Open published response
27 Jun 2022 Jessica Louise LAVERACK “Jessie” · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 11 Lack of national recognition of proactive collative vulnerability processes View source DASH form not adequately updated View source Lack of information sharing between agencies View source Lack of national-level complex case forums View source Lack of a single point of contact for information collation, assessment and coordinated proactive action View source Lack of a system to identify and care for vulnerable people outside the “high risk” criteria View source Failure of processes and policies to recognise the link between domestic abuse and suicide View source Insufficient information sharing about sleep deprivation risks and impacts on mental health and suicide View source Lack of a robust information-sharing policy for suicidal ideation, self-harm and vulnerable people View source Unavailability of a shared database for agencies to input common concerns View source Insufficient training and awareness of domestic abuse and suicide risk among front line police officers View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jessica Louise LAVERACK “Jessie” · 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
Jessica Louise LAVERACK “Jessie” had a history of domestic abuse, anxiety and alcohol dependence, and reported suicidal ideation and self-harm before her death. She was found on 2 February 2018, and the medical cause of death was recorded as hanging. The report identified concerns about the lack of a coordinated approach and information sharing between agencies, including for vulnerable people who did not meet the MARAC high-risk threshold.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national recognition of proactive collative vulnerability processes
Wider context from the report “(8) The processes of Humber police’s vulnerability hub and DARA forms which show a more proactive, collative approach, are not currently a nationally recognised method of working .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation DASH form not adequately updated
Wider context from the report “(7) Evidence was heard that the DASH form may benefit from updating .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 information sharing between agencies
Wider context from the report “(3) There was a lack of information sharing between all agencies , even those tasked with domestic abuse.
a. There is no one database which is accessible for all agencies to input their common concerns.
b. There is lack of robust policy of information sharing regarding both suicidal ideation, self harm as well as identification of the vulnerable.
It is noted that the Health and Care Act is due to commence on 1st July 2022, which outlines need for interagency working. This may be an ideal opportunity to address these issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national-level complex case forums
Wider context from the report “(9) If not already in place, to consider complex case forums on a national level .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 point of contact for information collation, assessment and coordinated proactive action
Wider context from the report “(4) There is no single point of contact to oversee the collation of all information, to appropriate assess it and to coordinate a structured proactive approach to people with dual or multi diagnosis. This is in both MARAC and for those who are vulnerable but do not meet the “high risk” criteria.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a system to identify and care for vulnerable people outside the “high risk” criteria
Wider context from the report “(2) There is no system to appropriately identify and care for the vulnerable who do not meet the criteria of “high risk” which is covered by MARAC, evidence was heard that a large number of domestic homicide reviews cover victims who have not been rated as “high risk”
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of processes and policies to recognise the link between domestic abuse and suicide
Wider context from the report “(1) The is a need for the recognition of the link between domestic abuse and suicide. Processes and policies do not seem to include this serious area to the extent that is required.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient information sharing about sleep deprivation risks and impacts on mental health and suicide
Wider context from the report “(11) To consider better information sharing about the risks of sleep deprivation and its impact on mental health and suicide .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust information-sharing policy for suicidal ideation, self-harm and vulnerable people
Wider context from the report “(3) There was a lack of information sharing between all agencies, even those tasked with domestic abuse.
a. There is no one database which is accessible for all agencies to input their common concerns.
b. There is lack of robust policy of information sharing regarding both suicidal ideation, self harm as well as identification of the vulnerable.
It is noted that the Health and Care Act is due to commence on 1st July 2022, which outlines need for interagency working. This may be an ideal opportunity to address these issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a shared database for agencies to input common concerns
Wider context from the report “(3) There was a lack of information sharing between all agencies, even those tasked with domestic abuse.
a. There is no one database which is accessible for all agencies to input their common concerns.
b. There is lack of robust policy of information sharing regarding both suicidal ideation, self harm as well as identification of the vulnerable.
It is noted that the Health and Care Act is due to commence on 1st July 2022, which outlines need for interagency working. This may be an ideal opportunity to address these issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient training and awareness of domestic abuse and suicide risk among front line police officers
Wider context from the report “(5) There is a need to consider better training and awareness of both domestic abuse and risk of suicide for front line police officers.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Home Office to implement the Tackling Domestic Abuse Plan.
Verbatim wording from the response “The Department recognises the links between domestic abuse and suicide. We are working closely with the Home Office on the implementation of its Tackling Domestic Abuse Plan. We will also continue to work closely with a range of partners across the suicide prevention sector to consider factors linked to suicide and actions that should be taken to address them as part of the recently announced national suicide prevention strategy. We expect this renewed strategy will include measures to tackle domestic abuse. Additionally, as near real time suspected suicide surveillance systems develop at a local and national level, the feasibility of improving data collection in relation to domestic abuse will be explored.” 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 Work with suicide prevention partners to consider suicide-linked factors and actions for the national suicide prevention strategy.
Verbatim wording from the response “The Department recognises the links between domestic abuse and suicide. We are working closely with the Home Office on the implementation of its Tackling Domestic Abuse Plan. We will also continue to work closely with a range of partners across the suicide prevention sector to consider factors linked to suicide and actions that should be taken to address them as part of the recently announced national suicide prevention strategy. We expect this renewed strategy will include measures to tackle domestic abuse. Additionally, as near real time suspected suicide surveillance systems develop at a local and national level, the feasibility of improving data collection in relation to domestic abuse will be explored.” 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 Confidential patient information cannot be shared without satisfying data protection law, public interest requirements and the Common Law Duty of Confidentiality case by case.
Verbatim wording from the response “With regard to your concerns around the general lack of information sharing between agencies, healthcare professionals must believe there is a significant public interest and satisfy data protection law, and the ‘Common Law Duty of Confidentiality’ when sharing any confidential patient information. This requires requestors to meet specific purposes on a case-by-case basis to ensure the confidentiality of this data is maintained.” Source location Response from Department of Health and Social Care
Open published response
24 Jun 2022 Grenville Wait · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Failure to meet target ambulance response times 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
Grenville Wait · 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
Grenville Wait fell while shopping, sustained a fractured sternum, and was later found deeply unconscious at home. He died after an ambulance response that was incorrectly coded as category 2 and arrived around 70 minutes after the 999 call; the principal concern was that target ambulance response times were routinely not being met 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 meet target ambulance response times
Wider context from the report “1) Notwithstanding the steps North West Ambulance Service NHS Foundation Trust has taken via its patient safety plan to manage and respond to demands on its service, it is a matter of concern that target response times are still routinely not being met nationally . By way of illustration, the court heard evidence that on 21st June 2021, the Trust’s average response time for a category 2 call was 50 minutes with the response time to 90% of all relevant incidents of 1 hour and 48 minutes.
” Open source report
17 Jun 2022 Amanda Hesketh · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Inadequate specialist input for patients prescribed multiple analgesics on repeat prescription View source Failure of GP practices with significant numbers of patients with complex analgesia regimes to engage practice pharmacists View source Lack of systematic review of patients receiving repeat prescriptions of multiple analgesics View source Failure to formulate individual plans for patients receiving repeat prescriptions of multiple analgesics 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
Amanda Hesketh · 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
Amanda Hesketh, who had a complex health history and was prescribed multiple analgesic medicines, became unresponsive in the Emergency Department after presenting with diarrhoea and vomiting and could not be resuscitated. The report identified concerns about the lack of systematic reviews and individual plans for patients receiving multiple analgesics, limited specialist pain-clinic input, and inconsistent use of practice pharmacists.
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 specialist input for patients prescribed multiple analgesics on repeat prescription
Wider context from the report “The court heard evidence from a General Practitioner as to difficulties patients encounter in accessing services from specialist pain clinics with lengthy waiting lists often being experienced. It is a matter of concern that patients being prescribed multiple analgesics continue to receive such medicines on repeat prescription with often with little or no specialist input ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of GP practices with significant numbers of patients with complex analgesia regimes to engage practice pharmacists
Wider context from the report “It is a matter of concern that GP practices who have a significant number of patients with complex analgesia regimes do not universally engage practice pharmacists to complement the knowledge of doctors and enhance the advice provided to 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 Lack of systematic review of patients receiving repeat prescriptions of multiple analgesics
Wider context from the report “Notwithstanding the actions the practice has taken in response to Mrs Hesketh’s death, it is a matter of concern the partnership has yet to undertake or commission a systematic review of all patients receiving repeat prescriptions of multiple analgesics and formulate individual plans for each such 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 Failure to formulate individual plans for patients receiving repeat prescriptions of multiple analgesics
Wider context from the report “Notwithstanding the actions the practice has taken in response to Mrs Hesketh’s death, it is a matter of concern the partnership has yet to undertake or commission a systematic review of all patients receiving repeat prescriptions of multiple analgesics and formulate individual plans for each such 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 Provide support and set expectations for clinical pharmacists working in general practice.
Verbatim wording from the response “In relation to your concern about General Practices engaging with practice pharmacists, you may wish to know that this Government has provided a high level of support and expectation in relation to pharmacists working in General Practice. Across England, General Practices are working together in Primary Care Networks (PCNs). One aspect of PCN work is supporting patients with structured medication reviews (SMRs), which are one of the PCN service requirements that commenced during 2020/21. Clinical pharmacists are best placed to carry out these reviews, and the Additional Roles Reimbursement Scheme (ARRS) provide PCNs with full reimbursement for clinical pharmacists amongst a variety of other roles.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation ICBs are responsible for commissioning specialist pain clinic services appropriate to their populations.
Verbatim wording from the response “Finally, it is within the remit of ICBs to commission services within their geographical area including specialist pain clinics and NHS England expects that ICBs commission appropriate pain clinic service provision to meet the needs of the population they serve.” 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 PCNs are responsible for workforce planning and delivering medication reviews; commissioners investigate and enforce breaches of PCN obligations.
Verbatim wording from the response “PCNs and their constituent General Practices are responsible for planning their workforce to fulfil their obligations under the PCN service requirements. Additionally, the DES specifications state that a PCN is required to offer and deliver a volume of SMRs determined and limited by the PCN’s clinical pharmacist capacity, and the PCN must demonstrate reasonable ongoing efforts to maximise that capacity. Further, where a PCN has been identified as potentially breaching the obligations within the service requirements, commissioners should undertake any necessary and appropriate investigation and contract enforcement action.” Source location Response from Department of Health and Social Care
Open published response
16 Jun 2022 Lee Anthony CARUANA · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Delays in handing over ambulance patients at hospitals 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
Lee Anthony CARUANA · 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
Lee Anthony CARUANA died at the Queen Elizabeth Hospital, Birmingham, on 6 October 2021 after suffering from COVID-19 and experiencing a delay in ambulance attendance. The report identified delays caused by ambulance crews waiting to hand over patients at hospitals, compromising ambulance availability and creating a risk to life.
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 handing over ambulance patients at hospitals
Wider context from the report “1. During the inquest, evidence was given on behalf of West Midlands Ambulance Service from Clinical Governance Lead ████████ and Trust Investigations Officer ████████ that at the time of Mr Caruana's death the Trust was experiencing unprecedented demand due to high call volume and delays in handing over patients to hospitals . At the time Mr Caruana was identified as needing an ambulance following a 999 call at 23:53 on the 6 October 2021, 71 of the Trusts 253 ambulance crews on duty were at hospital awaiting handover, the longest wait that day had been 7 hours and 45 minutes for a crew waiting at Birmingham Heartlands Hospital.
2. Since October 2021 the number of calls received has started to reduce to normal levels. However, the problem of paramedic crews being stuck at hospitals awaiting handover has increased . As an Investigations Officer ████████ said she is continuing to see incidents where ambulance attendance has been delayed because a crew was not available due to the number of crews waiting at hospital . Her evidence was that this is putting lives at risk.
3. ████████, Governance and Performance Manager at London Ambulance Service, gave evidence to the inquest as an independent expert. In the course of his evidence, he explained that the problem of ambulance crews being stuck awaiting handover is a national issue . Based on his anecdotal experience and observations the number of calls that a crew is able to attend to in a 12 hour shift has dropped by approximately 1/3 as a result of this issue.
4. The evidence from West Midlands Ambulance Service is that they have raised awareness of this issue locally, they have taken steps to free up ambulances (such as leaving multiple patients under the care of one paramedic crew at hospital to free up other crews to leave and diverting patients to other services where possible) and there is nothing further that they can do.
5. In the circumstances it is my conclusion that the availability of ambulance crews is being compromised by delays at hospitals resulting in delays in response times which creates a risk to life .
” Open source report
15 Jun 2022 Marjorie Walker · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Delays in accessing specialist pain clinics View source Failure to complete and document DNA CPR decisions in accordance with protocols View source Lack of understanding and recognition of kidney-function monitoring alongside prescribing of pain medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marjorie 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
Marjorie Walker was found unresponsive in hospital on 27 May 2020 after receiving prescribed gabapentin, morphine and buprenorphine, with post-mortem toxicology finding gabapentin above the therapeutic level. The report describes concerns about an incorrectly completed DNA CPR form, delays in specialist pain-clinic access, and insufficient recognition and monitoring of kidney function when prescribing gabapentin and other pain medication.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in accessing specialist pain clinics
Wider context from the report “2. Mrs Walker had lived with significant chronic pain for many years. Evidence was heard that she would have benefited from an appointment with a pain clinic for specialist input and the risks around pain medication could have been reduced with specialist input. The inquest heard that there were significant delays in accessing specialist pain clinics due to demand and capacity issues across the NHS ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and document DNA CPR decisions in accordance with protocols
Wider context from the report “1. The inquest heard evidence that despite the consequences for a patient of a DNA CPR it had not been completed in accordance with protocols . The inquest heard evidence that the importance of well documented and correctly completed paperwork in relation to DNA CPR was important in all cases but particularly in relation to vulnerable members of the community such as Mrs Walker;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding and recognition of kidney-function monitoring alongside prescribing of pain medication
Wider context from the report “3. Mrs Walker was prescribed Gabapentin as part of helping her to manage her chronic pain. The evidence was that the use of pain medication such as Gabapentin carried risk particularly in relation to a patient with underlying kidney issues. The inquest was told that a lack of understanding and recognition of monitoring kidney function including clearance results by health professionals including pharmacists and doctors alongside prescribing created a risk of overdose particularly of vulnerable patients. The inquest was told that the risk would be reduced by greater ease of access to results, more robust checking and education.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with NHS England to deliver the plan for tackling the COVID-19 elective care backlog and provide support and challenge.
Verbatim wording from the response “A significant part of this funding will be invested in staff, both in terms of capacity and skills. However, the Department has also committed to a £5.9 billion investment in capital for new beds, equipment and technology. The Department will also continue to work closely with NHS England to deliver the ‘Delivery Plan for Tackling the COVID-19 Backlog of Elective Care’, providing the necessary support and challenge to make sure it benefits patients and delivers value for money.” 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 increased NHS staffing capacity and skills to support elective recovery and service transformation.
Verbatim wording from the response “Regarding your concern about significant delays to access specialist pain clinics, the pandemic has put enormous pressures on the NHS with elective waiting lists growing to over 7 million patients, but we remain committed to ensuring people get the right care at the right time. That is why we are delivering record staffing numbers, and putting in record levels of funding, to help the NHS recover and transform services. Having virtually met our target to eliminate long waits of two years or more for elective procedures in July 2022, our next ambition is to eliminate waits of eighteen months or more by April 2023.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make £2 billion of Elective Recovery Fund and £700 million of Targeted Investment Fund support available to healthcare systems.
Verbatim wording from the response “To support this elective recovery, the government plans to spend more than £8 billion from 2022-23 to 2024-25, in addition to the £2 billion Elective Recovery Fund and £700 million Targeted Investment Fund already made available to systems last financial year, to help drive up and protect elective activity. Taken together, this funding could deliver the equivalent of around nine million more checks and procedures and will mean the NHS in England can aim to deliver around 30% more elective activity by 2024-25 than before the pandemic.” 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 more than £8 billion in elective recovery funding from 2022–23 to 2024–25 to increase and protect elective activity.
Verbatim wording from the response “To support this elective recovery, the government plans to spend more than £8 billion from 2022-23 to 2024-25, in addition to the £2 billion Elective Recovery Fund and £700 million Targeted Investment Fund already made available to systems last financial year, to help drive up and protect elective activity. Taken together, this funding could deliver the equivalent of around nine million more checks and procedures and will mean the NHS in England can aim to deliver around 30% more elective activity by 2024-25 than before the pandemic.” 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 £5.9 billion in capital for new beds, equipment and technology.
Verbatim wording from the response “A significant part of this funding will be invested in staff, both in terms of capacity and skills. However, the Department has also committed to a £5.9 billion investment in capital for new beds, equipment and technology. The Department will also continue to work closely with NHS England to deliver the ‘Delivery Plan for Tackling the COVID-19 Backlog of Elective Care’, providing the necessary support and challenge to make sure it benefits patients and delivers value for money.” 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 ICBs commission local pain services; NHS England commissions only highly specialist pain services subject to eligibility criteria.
Verbatim wording from the response “Turning specifically to pain clinics, it is within the remit of Integrated Care Boards (ICBs) to commission services within their geographical area and NHS England expects ICBs to commission appropriate services to meet the needs of the population they serve, including services that can” Source location Response from Department of Health and Social Care
Open published response
15 Jun 2022 Keith Hopwood · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to automatically escalate disconnected ambulance calls from callers who are alone View source Insufficient ambulance service resources to meet demand View source Failure to categorise ambulance calls accurately for appropriate ambulance dispatch View source Failure of the ambulance call algorithm to direct exploration of concerning symptom responses 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
Keith Hopwood · 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
Keith Hopwood fainted and felt very unwell before calling an ambulance, reporting chest pain during a later call. He was found unresponsive at home and could not be resuscitated; the medical cause of death was myocardial infarction due to stenotic coronary artery atheroma. The concerns included delays and resource pressures in the ambulance service, failure to upgrade the call category, limitations in the call-handling algorithm, the use of a private ambulance not equipped to deal with a cardiac patient, and the handling of a disconnected call when he was alone.
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 automatically escalate disconnected ambulance calls from callers who are alone
Wider context from the report “4. The second call from Mr Hopwood disconnected. Because he was alone a disconnection does not automatically result in an escalation of a call . Had he been with someone who said he had become unresponsive that would have generated a different approach.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 to meet demand
Wider context from the report “1. The inquest heard that the delays in relation to the ambulance service were due to significant resource issues for all ambulance services not just North West Ambulance Service . The inquest was told that the shortages were due to staffing levels and demand . Steps had been taken to try to increase resources but the ambulance service was still struggling to meet the demand . In this case it was clear that had the initial ambulance not have been rerouted due to demand and pressure on services that he would have been alive when he was seen and have been transported to hospital;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to categorise ambulance calls accurately for appropriate ambulance dispatch
Wider context from the report “3. The ambulance that arrived was a private ambulance and not equipped to deal with a cardiac patient. If the second call had been correctly categorised it would not have been dispatched as private ambulances are deployed with less qualified staff to calls categorised as 3 and 4 due to a lack of NHS Ambulance resources. As a consequence a further ambulance had to be deployed to the scene when Mr Hopwood was found to be unresponsive;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 ambulance call algorithm to direct exploration of concerning symptom responses
Wider context from the report “2. The inquest heard that in the initial call to the ambulance service he was told to call back if he got worse in any way. His response was to say that he couldn’t feel any worse than he had in the last 10 minutes. The algorithm driving the conversation did not direct that this response should require exploration of symptoms and why he had made this comment . As a consequence an opportunity to explore his presentation further was lost;
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest in the ambulance workforce, increasing NHS ambulance and support staff numbers by over 40% since August 2010.
Verbatim wording from the response “We have made significant investments in the ambulance workforce, and the number of NHS ambulance staff and support staff has increased by over 40% since August 2010. Health Education England has a mandated target to train 3,000 paramedic graduates nationally per annum from 2021-2024, further increasing the domestic paramedic workforce to meet future demands on the service. St John Ambulance has also been contracted to deliver auxiliary ambulance services, providing national surge capacity of up to 5,000 hours per month to support the ambulance response during periods of increased pressure, allowing NHS ambulance crews to focus on responding to emergency calls.” Source location Response from Department of Health and Social Care
Open published response
9 Jun 2022 Shirley Alice Moloney · Prevention of Future Deaths report East London
View report summary
Concerns raised 10 Lack of establishments suitably designed for dual physical and mental health needs View source Failure to identify mental health concerns towards the end of life View source Insufficient resourcing of older age psychiatric teams View source Failure to provide community mental health services to older patients View source Absence of adequately trained staff to address mental health in residential home settings View source Lack of easy access to older age psychiatry teams for care homes and nursing homes View source Lack of older adult psychiatry resource for elderly patients View source Poorly defined access to care and support for psychological distress towards the end of life View source Insufficient availability of mental health nurses in care homes and nursing homes View source Delays in re-accessing older age community psychiatry teams after discharge 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
Shirley Alice Moloney · 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
Shirley Alice Moloney, who had longstanding paranoid schizophrenia and severe frailty, was found unresponsive at her care home on 10 December 2020 after suffering three vomits the previous day. The report states that it was likely she died from aspiration pneumonia and that the death was from natural causes. Concerns included the deterioration of her mental health and the lack of community mental health team care in the last nine months of her life, alongside wider concerns about access to older adult psychiatry for care-home 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 establishments suitably designed for dual physical and mental health needs
Wider context from the report “(ii) The inquest heard that older age psychiatric teams are very poorly resourced, nationally. This is compounded by an absence of adequately trained staff, to address mental health in residential home settings. The inquest also heard that there is a lack of establishments suitably designed for dual physical/mental health needs .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 mental health concerns towards the end of life
Wider context from the report “(iv) The inquest heard that mental health concerns can often be overlooked towards the end of life . Structures for accessing care for physical symptoms towards the end of life are well developed. Accessing care and support for psychological distress is not so well defined. Care homes and nursing homes tend to have mainly general nurses, as opposed to mental health nurses. They also have easy access to GPs and geriatricians. There is a perceived lack of easy access to older age psychiatry teams, by care homes and nursing homes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 resourcing of older age psychiatric teams
Wider context from the report “(ii) The inquest heard that older age psychiatric teams are very poorly resourced, nationally . This is compounded by an absence of adequately trained staff, to address mental health in residential home settings. The inquest also heard that there is a lack of establishments suitably designed for dual physical/mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 community mental health services to older patients
Wider context from the report “(i) Mrs Moloney suffered from paranoid schizophrenia. There was evidence of her mental state deteriorating in the months leading up to her death. Her mental health deterioration is likely to have impacted upon her physical health deterioration, but she was not under the care of community mental health services in the last nine months of her life .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 adequately trained staff to address mental health in residential home settings
Wider context from the report “(ii) The inquest heard that older age psychiatric teams are very poorly resourced, nationally. This is compounded by an absence of adequately trained staff, to address mental health in residential home settings . The inquest also heard that there is a lack of establishments suitably designed for dual physical/mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 easy access to older age psychiatry teams for care homes and nursing homes
Wider context from the report “(iv) The inquest heard that mental health concerns can often be overlooked towards the end of life. Structures for accessing care for physical symptoms towards the end of life are well developed. Accessing care and support for psychological distress is not so well defined. Care homes and nursing homes tend to have mainly general nurses, as opposed to mental health nurses. They also have easy access to GPs and geriatricians. There is a perceived lack of easy access to older age psychiatry teams, by care homes and nursing homes .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 older adult psychiatry resource for elderly patients
Wider context from the report “(v) As mental health and physical health are so closely inter-linked, the lack of older adult psychiatry resource for elderly patients , gives rise to a risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poorly defined access to care and support for psychological distress towards the end of life
Wider context from the report “(iv) The inquest heard that mental health concerns can often be overlooked towards the end of life. Structures for accessing care for physical symptoms towards the end of life are well developed. Accessing care and support for psychological distress is not so well defined . Care homes and nursing homes tend to have mainly general nurses, as opposed to mental health nurses. They also have easy access to GPs and geriatricians. There is a perceived lack of easy access to older age psychiatry teams, by care homes and nursing homes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of mental health nurses in care homes and nursing homes
Wider context from the report “(iv) The inquest heard that mental health concerns can often be overlooked towards the end of life. Structures for accessing care for physical symptoms towards the end of life are well developed. Accessing care and support for psychological distress is not so well defined. Care homes and nursing homes tend to have mainly general nurses, as opposed to mental health nurses . They also have easy access to GPs and geriatricians. There is a perceived lack of easy access to older age psychiatry teams, by care homes and nursing homes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 re-accessing older age community psychiatry teams after discharge
Wider context from the report “(iii) Once discharged from an older age community psychiatry team, it can take a very long time to access the teams again . These delays can act as a deterrent to GPs in referring patients to community mental health teams.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand NHS support in care homes and strengthen links with general practices and community services.
Verbatim wording from the response “Whilst there was no evidence that a lack of care contributed to Mrs Moloney’s death, we recognise the areas of concern you have identified that could contribute to future deaths. We are committed through the NHS Long Term Plan to offering more NHS support in care homes to ensure there are strong links between care homes, local general practices and community services.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce integrated community models giving adults and older adults with severe mental illness greater choice and control over care and support.
Verbatim wording from the response “Furthermore, through the NHS Long Term Plan, we are investing at least £2.3 billion additional funding a year to expand and transform mental health services in England by 2023/24. This will enable an extra two million people to be treated by NHS mental health services by 2023/24. This includes new integrated community models, giving 370,000 adults and older adults with severe mental illness greater choice and control over their care and support to live well in their communities by 2023/24.” 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 Work with NHS England on next steps following its consultation on proposed community mental-health waiting-time standards.
Verbatim wording from the response “We are also committed to setting clear standards for patients requiring access to community mental health treatment. NHS England has consulted on the potential to introduce five new waiting time standards as part of its clinically led review of NHS Access Standards. These include a proposal that adults and older adults presenting to community-based mental health services should start to receive help within four weeks from referral. NHS England published the outcomes of that consultation in February, and we are now working with them on the next steps.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase the mental-health workforce, including staffing capacity for community mental-health services for older adults.
Verbatim wording from the response “You have raised concerns around the resourcing of older age psychiatric teams. We recognise the need to increase capacity in NHS mental health services, including community mental health services for older adults, due to the increasing demand for services. The mental health workforce increased by 5,900 full-time equivalent staff in December 2021 compared with December 2020, and by over 11,800 compared to December 2010. However, we know there is more to do to ensure we have sufficient numbers of healthcare staff to deliver our aims for high quality, accessible mental health services for all ages. We therefore aim to expand the mental health workforce by an additional 27,000 healthcare professionals by 2023/24 (compared to 2019/20).” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Set clear standards for access to community mental-health treatment.
Verbatim wording from the response “We are also committed to setting clear standards for patients requiring access to community mental health treatment. NHS England has consulted on the potential to introduce five new waiting time standards as part of its clinically led review of NHS Access Standards. These include a proposal that adults and older adults presenting to community-based mental health services should start to receive help within four weeks from referral. NHS England published the outcomes of that consultation in February, and we are now working with them on the next steps.” 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 There was no evidence that a lack of care contributed to the death.
Verbatim wording from the response “Whilst there was no evidence that a lack of care contributed to Mrs Moloney’s death, we recognise the areas of concern you have identified that could contribute to future deaths. We are committed through the NHS Long Term Plan to offering more NHS support in care homes to ensure there are strong links between care homes, local general practices and community services.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local authorities and the CQC are responsible for the quality, delivery and availability of suitable care providers.
Verbatim wording from the response “With regard to your concerns around a lack of adequately trained staff in care homes, and a lack of establishments suitably designed for dual physical/mental health needs. The quality, delivery and availability of a suitable care provider sits within the responsibility of the local authority and the CQC. Where concerns on quality or safety are identified, the CQC have a wealth of enforcement powers available and will take swift action to ensure the safety of service users. Under the Care Act 2014 local authorities are responsible for achieving a responsive, diverse and sustainable market of service providers that can provide high quality, personalised care and support, to best meet the needs of people.” Source location Response from Department of Health and Social Care
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations