31 Jul 2020 Amy Hogan · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Unavailability of electronic access to regular GP records in out-of-hours care View source Failure to transfer complete patient data when patients move between general practices View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Amy Hogan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Amy Hogan reported feeling unwell from around September 2019 and attended an out-of-hours doctor on 20 January 2020 with light-headedness, weakness and exhaustion. She became acutely unwell and collapsed at home the following day, dying at hospital aged 23. The principal concerns were that her previous GP records had not transferred and that the out-of-hours GP could not electronically access her regular records, including information that she was prescribed the oral contraceptive pill.
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 electronic access to regular GP records in out-of-hours care
Wider context from the report “2) Notwithstanding numerous previous initiatives as to information-sharing and digitisation of patient data, it is a matter of concern that the out of hours GP receiving Miss Hogan had no electronic access to her regular GP records . Access to such records would have revealed, amongst other things, Miss Hogan was prescribed the oral contraceptive pill, which is likely to have led the doctor to ask additional questions about her symptoms. Again, it is a matter of particular concern that an inability to access regular GP records in the out of hours setting raises additional risks for vulnerable 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 transfer complete patient data when patients move between general practices
Wider context from the report “1) The inquest heard evidence from Miss Hogan’s regular GP that, despite being requested, the General Practice records from her previous practice never arrived . It is a matter of concern that delayed, incomplete or non-existent transfer of patient data from one practice to another on moving places an unfair burden on patients to accurately recall and relay their own medical histories. It is a matter of particular concern that such issues create particular problems for vulnerable patients, who simply may not be in a position to do so;
” Open source report
30 Jul 2020 Reginald Collins · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of suitable complex EMI bed capacity View source Delays in discharge via Adult Social Care 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
Reginald Collins · 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
Reginald Collins fell and fractured his neck of femur, underwent surgery, and remained in hospital after becoming medically optimised because a suitable placement was unavailable. He developed aspiration pneumonia and died on 22 October 2019; concerns included delays in discharge and the lack of suitable complex EMI beds locally and 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 Lack of suitable complex EMI bed capacity
Wider context from the report “1. The inquest heard that Mr Collins could have been discharged from 19th September when he was medically optimised. However he remained in an acute hospital setting until his death on 22nd October because of the challenges of finding a suitable EMI placement for him .
2. The inquest heard that an EMI placement would have met his needs in a way that an acute hospital setting could not.
3. The inquest was told that the delay was due in large part to a lack of suitable complex EMI beds both locally and nationally .
4. The delay in his discharge via Adult Social Care meant that an acute hospital bed was not available to 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 Delays in discharge via Adult Social Care
Wider context from the report “1. The inquest heard that Mr Collins could have been discharged from 19th September when he was medically optimised. However he remained in an acute hospital setting until his death on 22nd October because of the challenges of finding a suitable EMI placement for him.
2. The inquest heard that an EMI placement would have met his needs in a way that an acute hospital setting could not.
3. The inquest was told that the delay was due in large part to a lack of suitable complex EMI beds both locally and nationally.
4. The delay in his discharge via Adult Social Care meant that an acute hospital bed was not available to the Trust.
” Open source report
27 Jul 2020 Samuel Garner · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Lack of appropriate Emergency Department space for treating vulnerable patients View source Lack of surgical bed capacity delaying transfer from the Emergency Department View source Delays in performing clinically required chest drainage due to competing staff demands View source Failure to maintain sufficient Emergency Department capacity during recurring periods of high demand View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samuel Garner · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Samuel Garner had an accidental fall at a nursing home on 8 October 2019 and was admitted to hospital three days later, where rib fractures and a traumatic pneumothorax were diagnosed. He died in hospital on 19 October 2019. Concerns included treatment in the Emergency Department corridor, delays in draining his chest, and a significant delay in transfer to a surgical ward because of competing demands and limited bed capacity.
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 appropriate Emergency Department space for treating vulnerable patients
Wider context from the report “2. As a result of the lack of appropriate space Mr Garner for an elderly and vulnerable patient was treated in the corridor for periods during his stay in the ED . This included whilst he was being given antibiotics intravenously - he scored on the sepsis pathway on arrival. He was also moved in and out of bays depending on varying prioritisation of need .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of surgical bed capacity delaying transfer from the Emergency Department
Wider context from the report “4. It was identified at an early stage that he would need a surgical bed and his care would be optimised in such a setting. There was a significant delay in moving him from the Emergency Department to a surgical ward due to lack of bed capacity within 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 Delays in performing clinically required chest drainage due to competing staff demands
Wider context from the report “3. He waited a number of hours for his chest to be drained (after it was identified that was what was required) due to competing demands on clinical staff . He was in significant distress whilst waiting.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 sufficient Emergency Department capacity during recurring periods of high demand
Wider context from the report “1. The inquest heard evidence that on admission to Stepping Hill Hospital the Emergency Department was extremely busy due to the volume of patients in the department . This had been typical of the picture in both the preceding and following weeks due to winter pressures/demands .
” 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 additional funding to alleviate Covid-19 winter pressures and support NHS capacity.
Verbatim wording from the response “This year, we have provided an extra £3billion to alleviate the particular challenges brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale Hospitals and their surge capacity, as well as the NHS’s use of independent sector hospital capacity.” Source location 2020-0145-Response-from-DHSC_Redacted.pdf
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 Roll out support for care home residents so more people can receive care in their communities.
Verbatim wording from the response “The NHS Long Term Plan commits funding worth £4.5billion per year by 2023/24 to be focused on primary and community care. This includes a national roll-out of support for care home residents so more people can be looked after where they live. The NHS also aims to place therapy and social work teams at the beginning of the acute hospital pathway, setting an expectation that patients will have an agreed clinical care plan within 14 hours of admission, including an expected date of discharge.” Source location 2020-0145-Response-from-DHSC_Redacted.pdf
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 Nightingale Hospitals and their surge capacity.
Verbatim wording from the response “This year, we have provided an extra £3billion to alleviate the particular challenges brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale Hospitals and their surge capacity, as well as the NHS’s use of independent sector hospital capacity.” Source location 2020-0145-Response-from-DHSC_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue implementing Same Day Emergency Care to reduce non-elective hospital admissions.
Verbatim wording from the response “In 2019/20, this involved continued work to tackle both the increases in demand in urgent and emergency care and to ensure patients receive the quality of care they need and expect in a timely and safe manner. For example, the continued roll out of Urgent Treatment Centres, offering a consistent service to patients and introducing the ability to book appointments through NHS 111, as well as initiatives such as Same Day Emergency Care, to reduce non-elective admissions to hospital.” Source location 2020-0145-Response-from-DHSC_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue rolling out Urgent Treatment Centres, including appointment booking through NHS 111.
Verbatim wording from the response “In 2019/20, this involved continued work to tackle both the increases in demand in urgent and emergency care and to ensure patients receive the quality of care they need and expect in a timely and safe manner. For example, the continued roll out of Urgent Treatment Centres, offering a consistent service to patients and introducing the ability to book appointments through NHS 111, as well as initiatives such as Same Day Emergency Care, to reduce non-elective admissions to hospital.” Source location 2020-0145-Response-from-DHSC_Redacted.pdf
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 NHS 111 First to provide low-complexity digital care and direct patients to appropriate settings more quickly.
Verbatim wording from the response “Other elements of the NHS winter plan for 2020/21 include ‘NHS 111 First’ which will provide low complexity care digitally and ensure those who need more care can receive it in the right setting more quickly, rather than waiting in A&E².” Source location 2020-0145-Response-from-DHSC_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide funding to continue enhanced hospital discharge arrangements and maintain safe, timely patient discharge over winter.
Verbatim wording from the response “This year we made £1.3billion funding available via the NHS to support the hospital discharge process in March. As part of the £3billion funding for winter, an extra £588million has been confirmed to continue enhanced discharge arrangements over winter and maintain the safe and timely discharge of patients from hospital.” Source location 2020-0145-Response-from-DHSC_Redacted.pdf
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 NHS Long Term Plan funding for primary and community care by 2023/24.
Verbatim wording from the response “The NHS Long Term Plan commits funding worth £4.5billion per year by 2023/24 to be focused on primary and community care. This includes a national roll-out of support for care home residents so more people can be looked after where they live. The NHS also aims to place therapy and social work teams at the beginning of the acute hospital pathway, setting an expectation that patients will have an agreed clinical care plan within 14 hours of admission, including an expected date of discharge.” Source location 2020-0145-Response-from-DHSC_Redacted.pdf
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 NHS use of independent-sector hospital capacity.
Verbatim wording from the response “This year, we have provided an extra £3billion to alleviate the particular challenges brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale Hospitals and their surge capacity, as well as the NHS’s use of independent sector hospital capacity.” Source location 2020-0145-Response-from-DHSC_Redacted.pdf
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 Stockport health system partners are responsible for taking action to address urgent and emergency care safety concerns.
Verbatim wording from the response “It is essential that health system partners in Stockport take the necessary action, quickly, to respond to these findings and improve the safety and quality of urgent and emergency services in Stockport.” Source location 2020-0145-Response-from-DHSC_Redacted.pdf
Open published response
13 Jul 2020 John Cheetham · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of sufficient emergency department and inpatient bed capacity View source Failure to maintain adequate staffing by nurses trained to work in the emergency department View source Failure to prioritise timely risk assessments for elderly patients at risk of falls View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Cheetham · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Cheetham died at Stepping Hill Hospital on 19 January 2020 after an unwitnessed fall while awaiting a hospital bed in the Emergency Department, sustaining a subarachnoid haemorrhage and subsequently developing cerebral oedema and Clostridium difficile infection. The concerns included prolonged Emergency Department waits caused by bed-capacity pressures, shortages of appropriately trained nurses, and failure to complete a falls-risk assessment at the earliest opportunity, increasing risks for elderly patients vulnerable to falls.
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 sufficient emergency department and inpatient bed capacity
Wider context from the report “2. The evidence given to the inquest was that the Trust and all other acute hospitals in Greater Manchester were at that time facing significant challenges in terms of ED capacity . The capacity issues on that day were not one off but had been on going throughout December and continued through the winter months . As a result the ED was regularly overcrowded and elderly, vulnerable patients were regularly waiting for very long periods of time in unsuitable conditions in the ED .
3. The prolonged wait Mr Cheetham had was a result of lack of bed capacity . The inquest was told that this was due to delayed discharges of elderly in-patients back into the community because of challenges faced by adult social care. On the day that Mr Cheetham was waiting for a bed there were over 20 other patients in a similar position waiting for an in-patient bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain adequate staffing by nurses trained to work in the emergency department
Wider context from the report “4. The inquest was also told that a shortage of nurses nationally trained to work in ED had meant that the unit was short staffed on the night he fell and suffered a catastrophic 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 prioritise timely risk assessments for elderly patients at risk of falls
Wider context from the report “5. In his case a risk assessment was not carried out at the earliest opportunity . The inquest heard that when an ED is facing the demands caused by capacity issues risk assessments are not always prioritised increasing the risks faced by elderly patients at risk of falls .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce NHS 111 First to provide low-complexity care digitally and direct patients to appropriate settings more quickly.
Verbatim wording from the response “Other elements of the NHS winter plan for 2020/21 include ‘NHS 111 First’ which will provide low complex care digitally and ensure those who need more care can receive it in the right setting more quickly, rather than waiting in A&E².” Source location 2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
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 50,000 additional NHS nurses by 2025 through expanded training, recruitment and retention.
Verbatim wording from the response “In relation to the matter of concern in your report about a shortage of nurses trained to work in emergency departments, I would like to assure you that ensuring the NHS has the staff it needs, especially nursing staff who are also suitable bedrock of the NHS and care system, is and will remain, a priority for this Government. That is why we made our manifesto pledge to deliver 50,000 more nurses in our NHS by 2025, which we will achieve through a combination of investing in and diversifying our training pipeline, as well as recruiting and retaining more nurses in the NHS.” Source location 2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
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 Fund primary and community care, including national support for care homes, through the NHS Long Term Plan’s £4.5 billion annual commitment by 2023/24.
Verbatim wording from the response “The NHS Long Term Plan commits funding worth £4.5billion per year by 2023/24 to be focused on primary and community care. This includes a national roll-out of support for care homes so more people can be looked after where they live. The NHS also aims to place therapy and social work teams at the beginning of the acute hospital pathway, setting an expectation that patients will have an agreed clinical care plan within 14 hours of admission, including an expected date of discharge.” Source location 2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
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 NHS Trusts with a share of £300 million additional capital funding to upgrade facilities before winter.
Verbatim wording from the response “NHS Trusts across England, including the Stockport NHS Foundation Trust, will receive a share of £300million additional capital funding to upgrade their facilities ahead of this winter and ensure the NHS is prepared to cope with winter pressures and reduce the risks associated with further outbreaks of Covid-19.” Source location 2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
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 Nightingale hospitals, their surge capacity and NHS use of independent-sector hospital capacity.
Verbatim wording from the response “This year, we have provided an extra £3billion to alleviate the particular challenges brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale Hospitals and their surge capacity, as well as the NHS’s use of independent sector hospital capacity.” Source location 2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
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 £588 million to continue enhanced hospital-discharge arrangements over winter and maintain safe, timely discharge.
Verbatim wording from the response “This year we made £1.3billion funding available via the NHS to support the hospital discharge process in March. As part of the £3billion funding for winter, an extra £588million has been confirmed to continue enhanced discharge arrangements over winter and maintain the safe and timely discharge of patients from hospital.” Source location 2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue rolling out Urgent Treatment Centres, NHS 111 appointment booking and Same Day Emergency Care to manage urgent and emergency demand.
Verbatim wording from the response “In 2019/20, this involved continued work to tackle both the increases in demand in urgent and emergency care and to ensure patients receive the quality of care they need and expect in a timely and safe manner. For example, the continued roll out of Urgent Treatment Centres, offering a consistent service to patients and introducing the ability to book appointments through NHS 111, as well as initiatives such as Same Day Emergency Care, to reduce non-elective admissions to hospital.” Source location 2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
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 Stockport health system partners are responsible for implementing improvements addressing urgent and emergency care safety concerns.
Verbatim wording from the response “It is essential that health system partners in Stockport take the necessary action, quickly, to respond to these findings and improve the safety and quality of urgent and emergency services in Stockport.” Source location 2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Open published response
1 Jul 2020 Joan Margaret McIndoe · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of clarity about expectations for updates after call-centre calls to the ambulance service View source Failure to distinguish calls from residential facilities where contact cannot be established from calls where contact is lost during the call View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joan Margaret McIndoe · 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
Joan Margaret McIndoe was found unresponsive in the shower at her retirement complex after an alarm was activated and the call centre was unable to contact her. The ambulance call was categorised as a Category 4 response, and concerns were raised about the automatic categorisation of such calls and the lack of clarity about updates after a call centre contacts the ambulance service, particularly while the alarm continued to activate.
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 clarity about expectations for updates after call-centre calls to the ambulance service
Wider context from the report “2. During the course of the inquest evidence was given that there is a lack of clarity about expectations for updates once a call has been placed by a call centre to the ambulance service . As a result there is no way of understanding if the position is evolving for example as in this case where the alarm kept going off and there was still no response from Mrs McIndoe.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 distinguish calls from residential facilities where contact cannot be established from calls where contact is lost during the call
Wider context from the report “1. The inquest was told that all such calls as this from residential facilities where contact cannot be established with the resident are automatically categorised as a Category 4 response by the ambulance service. This is in contrast to where a call is initiated and then contact is lost during the call .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The AACE cannot mandate or instruct ambulance services, limiting its authority to require implementation of responsive safety changes.
Verbatim wording from the response “The AACE provides central support and co-ordination to ambulance services to assist with implementation of national policy and the improvement of patient care. Although the AACE is not constituted to mandate or instruct ambulance services, it facilitates and enables the development of good practice. This includes consideration of concerns identified by coroners, where the AACE’s National Ambulance Medical Directors Group will discuss and disseminate learning from Prevention of Future Deaths reports. The concerns in your report have been brought to the attention of the AACE.” Source location 2020-0138-Response-from-Dept-for-Health-and-Social-Care_Redacted.pdf
Open published response
Concerns raised 1 Failure to ensure midwives have sufficient experience before taking up community posts View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Harrison Colin Hassall · 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
Harrison Colin Hassall was born pre-term and breech on 12 January 2019 after delayed delivery, and sustained brain damage before dying peacefully in hospital on 14 January 2019. Evidence highlighted concerns that midwives may be permitted to work in the community too soon after qualifying, with insufficient experience, and the University Hospital of Leicester NHS Trust indicated it would review the appropriate grade for community posts.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure midwives have sufficient experience before taking up community posts
Wider context from the report “It was highlighted in evidence that midwives may be permitted to work in the community too soon after qualifying and therefore may not have enough experience . The University Hospital of Leicester NHS Trust have indicated that they will be reviewing the appropriate Grade that a midwife should have attained before taking up a community post. This is not a matter that is relevant to only Leicester.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Employers are responsible for designing and delivering preceptorship programmes for newly registered midwives.
Verbatim wording from the response “Preceptorships provide a period of guidance and support to newly qualified practitioners that supplements formal induction and mandatory training and can positively influence a new registrant’s career, supporting them to become confident professionals. In July 2020, the NMC published principles for preceptorship², to support organisations and employers across the UK to achieve consistently high quality and effective preceptorship for newly registered nurses, midwives and nursing associates in the UK. NHS Trusts and other employers can use the NMC’s recently published principles of preceptorship to design and deliver effective, high quality preceptorship programmes.” Source location 2020-0111-Response-from-Department-of-Health-and-Social-Care.pdf
Open published response
4 May 2020 Barry Wayne Preston · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 10 Placement without a clear understanding of the person's needs View source Failure to provide suitable ward placement due to capacity and flow constraints View source Failure to supervise eating when supervision is required View source Lack of interagency understanding of roles and responsibilities View source Failure of care coordinators to lead support and best-interests processes in acute settings View source Unclear responsibility for care decisions and placement suitability assessment View source Failure to ensure food is served at a safe temperature View source Poor-quality care documentation View source Lack of coordination and ownership of care in acute settings View source Failure to recognise lack of decision-making capacity 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
Barry Wayne Preston · 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
Barry Wayne Preston, who lacked capacity and lived in supported accommodation, suffered a series of falls and traumatic brain injuries before developing urosepsis associated with a catheter that was not replaced within the guidance period, followed by bronchopneumonia. The report identified concerns about inaccurate documentation, unsuitable placement and wards, inadequate coordination and ownership of care, failures to hold best interests meetings, and insufficient understanding of his lack of capacity.
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 Placement without a clear understanding of the person's needs
Wider context from the report “7. His placement at Laburnum Lodge was made without a clear understanding of his needs . He fell twice within 24 hours sustaining a further bleed to his brain and readmission to the acute 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 provide suitable ward placement due to capacity and flow constraints
Wider context from the report “2. The inquest heard that he was kept on wards that were not suitable for him or his needs . The inquest was told that this was due to capacity and flow issues within the Royal Bolton 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 supervise eating when supervision is required
Wider context from the report “6. The inquest heard that whilst an in-patient he was served a pudding that was so hot that, while eating it unsupervised , he dropped it on himself and suffered a burn. The burn did not contribute to his death but did cause significant additional discomfort.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 interagency understanding of roles and responsibilities
Wider context from the report “3. The inquest heard that he had a care coordinator in the community. However the care coordinator did not take a lead in ensuring he was being supported in the acute settings or that best interests meetings were taking place. There was a lack of understanding between agencies of roles and responsibilities under the integrated care 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 Failure of care coordinators to lead support and best-interests processes in acute settings
Wider context from the report “3. The inquest heard that he had a care coordinator in the community. However the care coordinator did not take a lead in ensuring he was being supported in the acute settings or that best interests meetings were taking place . There was a lack of understanding between agencies of roles and responsibilities under the integrated care 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 Unclear responsibility for care decisions and placement suitability assessment
Wider context from the report “4. The inquest heard that whilst he was being treated in acute settings there was no coordination or ownership of his care. It was unclear as to who was making decisions and assessing suitability of placement .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure food is served at a safe temperature
Wider context from the report “6. The inquest heard that whilst an in-patient he was served a pudding that was so hot that, while eating it unsupervised, he dropped it on himself and suffered a burn . The burn did not contribute to his death but did cause significant additional discomfort.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor-quality care documentation
Wider context from the report “1. The quality of the documentation was not always of a good standard and part of the reason why his catheter was incorrectly believed to be a long term catheter.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 coordination and ownership of care in acute settings
Wider context from the report “4. The inquest heard that whilst he was being treated in acute settings there was no coordination or ownership of his care . It was unclear as to who was making decisions and assessing suitability of placement.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise lack of decision-making capacity
Wider context from the report “5. The inquest was told that for a long period of time whilst in the care of the NHS there was not a clear understanding of his lack of capacity to make decisions about his care . Acquiescence by him was seen as him understanding and having capacity .
” 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 Share the report’s concerns with NHS England and NHS Improvement to inform work on coordinated community mental health services.
Verbatim wording from the response “Officials have shared the concerns in your report with NHSEI so that they can be considered as work to deliver improved, co-ordinated community mental health services progresses, in particular, guidance to mental health trusts on partnership working and use of the Care Programme Approach, especially when the person has mental and physical health issues.” Source location 2020-0110-Response-from-Department-of-Health-and-Social-Care.pdf
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 Contact Bolton’s Principal Social Worker and the Greater Manchester Mental Health NHS Foundation Trust’s Director of Nursing and Governance to discuss progress on integrated care changes and protocols.
Verbatim wording from the response “In light of your report, the Chief Social Workers for Adults office will make contact with the Principal Social Worker for Bolton and the Director of Nursing and Governance at the Greater Manchester Mental Health NHS Foundation Trust to discuss the progress that both organisations have made in developing and implementing changes to their integrated care model and protocols for people with physical and mental health issues.” Source location 2020-0110-Response-from-Department-of-Health-and-Social-Care.pdf
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, service providers and the Care Quality Commission are responsible for acting on allegations of poor care, neglect or abuse.
Verbatim wording from the response “The Government is committed to preventing and reducing the risk of harm to adults in vulnerable situations. Under the Care Act 2014, we expect local authorities to ensure that the services they commission are safe, effective and of high quality. We also expect those providing the service, local authorities and the Care Quality Commission (CQC) to take swift action where anyone alleges poor care, neglect or abuse.” Source location 2020-0110-Response-from-Department-of-Health-and-Social-Care.pdf
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 Bolton NHS Foundation Trust, Greater Manchester Mental Health NHS Foundation Trust and Bolton Council are responsible for responding to the report’s specific concerns.
Verbatim wording from the response “I expect the Bolton NHS Foundation Trust, the Greater Manchester Mental Health NHS Foundation Trust and Bolton Council to carefully consider and respond to the specific concerns highlighted by your report. I am advised that Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust have apologised for the lack of co-ordination in Mr Preston’s care while he was in hospital and the failure to conduct a formal assessment of Mr Preston’s mental capacity. You will know from the responses of the NHS trusts and Bolton Council to your report that they have worked together to resolve the matters of concern highlighted, with several actions taken to improve the co-ordination and quality of care for people with physical and mental health problems. I am pleased to see that learnings are being taken from the circumstances around Mr Preston’s care.” Source location 2020-0110-Response-from-Department-of-Health-and-Social-Care.pdf
Open published response
27 Apr 2020 Evelyn Ross · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Failure to follow falls risk policy View source Failure to maintain sufficiently detailed clinical documentation View source Lack of a clear system of regular orthogeriatric consultant reviews View source Delays in arranging suitable community care packages for discharge View source Failure to escalate deterioration to a consultant View source Lack of sufficient and appropriately experienced ward staffing View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Evelyn Ross · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Evelyn Ross fractured her hip, underwent surgery, and was transferred for rehabilitation. After a fall, delayed CT scanning identified an acute on chronic subdural haematoma, followed by surgery, deterioration with hospital-acquired pneumonia, and her death on 23 September 2019. Concerns included staffing shortages, delays arranging discharge care, inadequate documentation, failure to follow the falls risk policy, and a lack of clear regular orthogeriatric consultant reviews and escalation when her condition deteriorated.
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 follow falls risk policy
Wider context from the report “4. The inquest heard that the Trust had not followed their own falls risk policy in relation to Mrs Ross.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 sufficiently detailed clinical documentation
Wider context from the report “3. During the course of the inquest the documentation relied on by the trust was lacking in detail and meant that it was difficult to understand her condition at key points or to understand the rationale for decisions .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear system of regular orthogeriatric consultant reviews
Wider context from the report “5. There did not appear to be a clear system of regular orthogeriatric consultant reviews of Mrs Ross. This meant that there was no escalation of her condition to a consultant when she began to show signs of deterioration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 arranging suitable community care packages for discharge
Wider context from the report “2. The inquest was told that whilst Mrs Ross was medically fit for discharge prior to 1st July she had not been discharged because of delays in arranging a suitable care package to support her in the community .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 deterioration to a consultant
Wider context from the report “5. There did not appear to be a clear system of regular orthogeriatric consultant reviews of Mrs Ross. This meant that there was no escalation of her condition to a consultant when she began to show signs of deterioration .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 sufficient and appropriately experienced ward staffing
Wider context from the report “1. The inquest was told that the ward in question had been short staffed for a number of months . As a result there was a reliance on agency staff and less experienced staff . The trust was now seeking to resolve the issue but it was still not fully resolved . It reflected a wider issue of a national shortage of nurses.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver 50,000 additional NHS nurses by 2025 through expanded training, recruitment and retention.
Verbatim wording from the response “However, we of course accept we need to do more and that is why on 18 December 2019, the Government announced a commitment to deliver 50,000 more nurses in our NHS by 2025. We will do this through a combination of investing in and diversifying our training pipeline, as well as recruiting and retaining more nurses in the NHS.” Source location 2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
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 financial support grants to eligible nursing, midwifery and allied health professional students, including additional support for childcare and shortage areas.
Verbatim wording from the response “This Government has already taken steps to deliver this commitment through our recently announced financial support package for eligible students. Eligible pre-registration nursing, midwifery and most allied health professional students on courses at English universities from September 2020 will benefit from grants of at least £5,000 per academic year. There will be up to £3,000 additional funding for some students to help with childcare costs or who choose to study in regions or specialisms struggling to recruit, including with priority given to shortage groups that are key to delivering the NHS Long Term Plan². None of this funding will have to be paid back.” Source location 2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and improve NHS-owned staff banks, including collaborative banks, to provide flexible staffing and reduce agency reliance.
Verbatim wording from the response “We recognise that to fully eliminate unnecessary agency spending, the Department and the NHS need to support trusts in developing a viable alternative source of flexible staffing in the form of in-house Staff Banks. Having reduced the rate of agency spending, we are now entering a new phase of work, focusing on the creation and improvement of staff banks, wherein existing NHS staff, who choose to work flexibly, can do so through an NHS owned bank, as opposed to a privately-owned agency. In the context of staff shortages in the NHS, in-house staff banks, and especially collaborative banks, create a larger pool of flexible staff, ensuring better quality and continuity of care, and reducing unnecessary agency spending by avoiding expensive commission.” Source location 2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make £1.3 billion available through the NHS to fund follow-on care and support patients safely and quickly after hospital discharge during the pandemic.
Verbatim wording from the response “During the COVID-19 pandemic, we are supporting health and care organisations to ensure we have the capacity to meet the needs of people affected by the virus. The COVID-19 Hospital Discharge Service Requirements published on 19 March are helping to reduce the friction surrounding funding decisions and assessments and focus on getting people out of hospital with the right support as soon as they are medically fit. We have made £1.3 billion funding available via the NHS to help patients who no longer need urgent treatment to get home from hospital safely and quickly. This funding will cover the follow-on care costs for adults in social care, and people in need of additional support, when they are out of hospital and back in their homes, community or care settings, during the pandemic.” Source location 2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Health Education England leads national workforce education, training and workforce supply arrangements.
Verbatim wording from the response “In terms of the health and care workforce overall, Health Education England (HEE) provides leadership for the education and training system at a national level. HEE ensures that the workforce has the right skills, behaviours and training, and is available in the right numbers.” Source location 2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS organisations and local partners, including social services, are responsible for timely discharge and ongoing care arrangements.
Verbatim wording from the response “It is the responsibility of the NHS and its local partners, including social service departments, to ensure that no patient remains in a hospital bed for longer than clinically necessary and that any ongoing care and support can begin promptly. Discharge arrangements from hospital should start before a patient is ready for discharge and the hospital should involve local social services at the earliest opportunity to plan post-discharge care and avoid delays.” Source location 2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing NICE falls guidance provides the relevant framework for identifying and addressing inpatient environmental and individual fall risks.
Verbatim wording from the response “Finally, with regard to falls prevention, the National Institute for Health and Care Excellence (NICE) has published a clinical guideline on Falls in older people: assessing risk and prevention (CG161³) that includes guidance on preventing falls in older people during a hospital stay. The guideline says:” Source location 2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
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 Individual NHS trusts are responsible for determining staffing numbers, staff types and agency staff use.
Verbatim wording from the response “Individual NHS Trusts are responsible for the number and type of staff they employ and they must ensure that there are sufficient staff and that those staff are trained and competent to carry out their duties. This applies equally to the usage of agency staff, which is a local decision for individual employers.” Source location 2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
Open published response
24 Apr 2020 Mary Brady · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Failure to implement controls to prevent recurrence of unsafe clinical waste disposal View source Failure to dispose of clinical waste in the designated secure clinical waste bin View source Failure to escalate recurring unsafe clinical waste disposal to senior managers View source Failure to update care plans following identified mouthing risks View source Failure to document and risk assess observed mouthing of foreign non-food items View source Failure to prevent unsupervised access by residents with dementia to hazardous waste in communal areas View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mary Brady · 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
Mary Brady, who had vascular dementia and lived in a care home, was found unresponsive after being left unobserved in a communal area. A used pair of latex gloves was removed from her airway, and she died shortly after midnight on 11 March 2019. Concerns included accessible open waste baskets, improper disposal and insufficient escalation of used gloves, and failures to document and risk-assess her previous ingestion of non-food items or update her care plan.
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 implement controls to prevent recurrence of unsafe clinical waste disposal
Wider context from the report “2. The gloves were clinical waste and had been disposed of other than in the clinical waste bin in the secure area. The inquest heard that there had been previous instances of used gloves being found in the waste baskets. However the issue had not been escalated to senior managers and no steps had been taken to avoid the issue reoccurring .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 dispose of clinical waste in the designated secure clinical waste bin
Wider context from the report “2. The gloves were clinical waste and had been disposed of other than in the clinical waste bin in the secure area . The inquest heard that there had been previous instances of used gloves being found in the waste baskets. However the issue had not been escalated to senior managers and no steps had been taken to avoid the issue reoccurring.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 recurring unsafe clinical waste disposal to senior managers
Wider context from the report “2. The gloves were clinical waste and had been disposed of other than in the clinical waste bin in the secure area. The inquest heard that there had been previous instances of used gloves being found in the waste baskets . However the issue had not been escalated to senior managers and no steps had been taken to avoid the issue reoccurring.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 update care plans following identified mouthing risks
Wider context from the report “3. Mrs Brady had been seen putting foreign non-food items in her mouth by staff. These instances had not been appropriately documented and risk assessed. The level of risk she presented was not fully understood as a result and her care plan was not updated .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to document and risk assess observed mouthing of foreign non-food items
Wider context from the report “3. Mrs Brady had been seen putting foreign non-food items in her mouth by staff. These instances had not been appropriately documented and risk assessed . The level of risk she presented was not fully understood as a result and her care plan was not updated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent unsupervised access by residents with dementia to hazardous waste in communal areas
Wider context from the report “1. The inquest heard that the home at the time of Mrs Brady’s death, in common with many similar establishments had open waste paper baskets in the communal areas . Residents with dementia were left unsupervised in these areas and there was always a risk that they might access material from these waste baskets . In this case the gloves should not have been in the bin at all but there were other items in there which could have presented a choking hazard . The home had since removed all open wastebaskets from communal areas to avoid the risk. The inquest was told that similar baskets were common in care homes nationally.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing CQC regulatory action and continued monitoring are considered sufficient to reduce further risks at the care home.
Verbatim wording from the response “You issued your report to the Care Quality Commission (CQC) and Departmental officials have made enquiries with the CQC on the regulatory activity in relation to this incident. I am therefore aware that following a review of the circumstances of Mrs Brady’s death; information provided by the registered provider and the action it has taken; and the findings of a CQC inspection conducted in February 2019, the CQC is satisfied that sufficient action has been taken to reduce further risks within the Balmoral Care Home and that there was insufficient evidence that a breach of the Regulations¹ had occurred. The CQC’s response to your report provides further detail on its considerations in relation to this case.” Source location 2020-0105-Response-from-the-Department-of-Health-and-Social-Care.pdf
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 Registered providers and service managers are responsible for safe care, local risk assessments and mitigating environmental and other risks.
Verbatim wording from the response “Registered providers and managers of services are expected to ensure they are delivering care safely and doing all they can to mitigate risks through the conduct of local risk assessments (including for example, assessing environmental risks such as those associated with open wastebaskets). Providers are expected to plan care in line with good practice standards, such as guidance issued by the National Institute for Health and Care Excellence (NICE), and relevant professional and regulatory bodies.” Source location 2020-0105-Response-from-the-Department-of-Health-and-Social-Care.pdf
Open published response
Concerns raised 2 Lack of funding and implementation of the Integrated Drug Treatment System in Wales View source Failure to automatically offer opiate substitution therapy on the day of arrival to eligible prisoners 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
DEAN GARY GEORGE · 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
DEAN GARY GEORGE was found hanging in his cell at HMP Swansea on 16 March 2016 and the inquest concluded that his death was a suicide caused by hanging. Concerns included unequal access to opiate substitution therapy in Welsh prisons, inadequate risk assessment, insufficient information sharing between medical and prison staff, inadequate ACCT training, and an inequitable opiate detoxification system.
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 funding and implementation of the Integrated Drug Treatment System in Wales
Wider context from the report “The evidence was that drug treatment in Wales is organised differently to that in England. Integrated Drug Treatment System had not been funded and implemented in Wales. The main difference between English and Welsh prisons is that those arriving from the community who are addicted to opiates but not engaged with community treatment are not automatically offered opiate substitution therapy on the day of arrival. There is a concern over this inequality in health care provision There have been Inquiries into this in the Welsh Assembly the most recent in 2019.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 offer opiate substitution therapy on the day of arrival to eligible prisoners
Wider context from the report “The evidence was that drug treatment in Wales is organised differently to that in England. Integrated Drug Treatment System had not been funded and implemented in Wales. The main difference between English and Welsh prisons is that those arriving from the community who are addicted to opiates but not engaged with community treatment are not automatically offered opiate substitution therapy on the day of arrival . There is a concern over this inequality in health care provision There have been Inquiries into this in the Welsh Assembly the most recent in 2019.
” Open source report
20 Apr 2020 Theo Benjamin Young · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Insufficient detail in final investigation reports View source Factual errors and inaccuracies in initial investigation reports View source Delays in final investigation report completion View source Delays in HSIB investigation completion View source Restriction of Trust-led investigation during HSIB investigations 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
Theo Benjamin Young · 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
Theo Benjamin Young was born by emergency caesarean section in a very poor condition after persistent abnormalities in fetal monitoring were not recognised during labour. He suffered non-survivable injuries from intrapartum hypoxia and died three days after delivery. Concerns included failures in staffing, fetal monitoring, escalation and oxytocin management, as well as delays and deficiencies in the subsequent HSIB investigation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail in final investigation reports
Wider context from the report “3. The initial draft report contained factual errors and inaccuracies requiring considerable input by the Trust to resolve. The final report is insufficiently detailed and was completed 18 months after the death, during which time further deaths could have resulted.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Factual errors and inaccuracies in initial investigation reports
Wider context from the report “3. The initial draft report contained factual errors and inaccuracies requiring considerable input by the Trust to resolve. The final report is insufficiently detailed and was completed 18 months after the death, during which time further deaths could have resulted.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 final investigation report completion
Wider context from the report “3. The initial draft report contained factual errors and inaccuracies requiring considerable input by the Trust to resolve. The final report is insufficiently detailed and was completed 18 months after the death , during which time further deaths could have resulted.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 HSIB investigation completion
Wider context from the report “2. HSIB indicated to the Trust at the outset that their investigation would take approximately six months which is highly likely to delay the introduction of any immediate necessary measures by the Trust to prevent further 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 Restriction of Trust-led investigation during HSIB investigations
Wider context from the report “1. The HSIB specifically requested the Trust not to undertake their own investigation effectively preventing the recognition of causes of concern and therefore being unable to undertake any immediate and necessary remedial action at the earliest opportunity to prevent future deaths.
” 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 HSIB disputes that inaccuracies in its investigation of Theo Young’s death resulted from error on its part.
Verbatim wording from the response “In relation to the quality of the investigation by HSIB of Theo’s death, HSIB advises that this was conducted in line with the statutory Directions and disputes that inaccuracies were due to error on its part.” Source location 2020-0094-Response-from-the-Department-of-Health-and-Social-Care
Open published response
24 Mar 2020 Simon Anthony Delahunty · Prevention of Future Deaths report North London
View report summary
Concerns raised 1 Lack of arrangements or guidance for the collection or disposal of unused end-of-life prescription medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Simon Anthony Delahunty · 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
Simon Anthony Delahunty took an overdose of medication prescribed for another patient, which had been left at an address as part of end-of-life care. The principal concern was that there were no arrangements or guidance for collecting or disposing of unused end-of-life prescription 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 Lack of arrangements or guidance for the collection or disposal of unused end-of-life prescription medication
Wider context from the report “There are no arrangements or guidance concerning the collection or disposal of unused end of life prescription medication.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing pharmacy return, secure storage, collection, and disposal arrangements provide a safe method for disposing of unwanted medicines.
Verbatim wording from the response “Disposal of unwanted medicines is an essential service of the NHS Community Pharmacy Contractual Framework¹, to be provided by all community pharmacies in England. This requires them to accept unwanted medicines from private households, residential care homes and children’s homes. These returned medicines are then stored securely and safely by pharmacies until they are collected for safe disposal.” Source location 2020-0077-Response-from-Dept-of-Health-and-Social-Care_Redacted
Open published response
12 Mar 2020 Mitica Marin · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to review the defibrillator during resuscitation View source LP15 defibrillator defaulting to manual mode View source Failure to activate the LP15 defibrillator in automatic mode View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mitica Marin · 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
Mitica Marin, aged 35, was found unresponsive at home on 11 April 2019 and died in hospital after prolonged resuscitation attempts. The cause of death was unascertained. The LAS investigation identified a four-minute delay in delivering the first defibrillator shock while Mr Marin was in a shockable rhythm, associated with the defibrillator being used in manual rather than automatic mode.
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 review the defibrillator during resuscitation
Wider context from the report “The LAS serious incident investigation identified a 4-minute delay between LP15 defibrillator pads being placed on Mr Marin’s chest and the administration of the first shock. During this period Mr Marin’s heart was in a shockable rhythm.
Paramedic A accepted that they had not reviewed the defibrillator as they were distracted by events.
Paramedic A did not activate the defibrillator in “automatic” mode. Had this setting been applied, any shockable rhythm would have been detected and an alert would have prompted the paramedic to shock to the patient.
This is not an isolated incident, the LAS conceded that it had undertaken a review of similar cases of delayed defibrillation. The review found that a factor was that the LP15 defibrillator model, defaults to manual mode requiring the user to switch to automatic mode before use.
2 studies cited by the LAS indicated that every minute a patient is delayed effective resuscitation; their prospects of survival diminishes by between 10-22%.
The LAS have introduced remedial measures to prevent such actions occurring, incorporating; training on the use of the LP15, labelling on units and the issuing of revised guidance.
If the LP15 defaulted to automatic mode or on start-up required, the choice of manual or automatic mode it is possible that such delays could be avoided.
I understand that procurement decisions regarding the future supply of defibrillators are imminent.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation LP15 defibrillator defaulting to manual mode
Wider context from the report “The LAS serious incident investigation identified a 4-minute delay between LP15 defibrillator pads being placed on Mr Marin’s chest and the administration of the first shock. During this period Mr Marin’s heart was in a shockable rhythm.
Paramedic A accepted that they had not reviewed the defibrillator as they were distracted by events.
Paramedic A did not activate the defibrillator in “automatic” mode. Had this setting been applied, any shockable rhythm would have been detected and an alert would have prompted the paramedic to shock to the patient.
This is not an isolated incident, the LAS conceded that it had undertaken a review of similar cases of delayed defibrillation. The review found that a factor was that the LP15 defibrillator model, defaults to manual mode requiring the user to switch to automatic mode before use.
2 studies cited by the LAS indicated that every minute a patient is delayed effective resuscitation; their prospects of survival diminishes by between 10-22%.
The LAS have introduced remedial measures to prevent such actions occurring, incorporating; training on the use of the LP15, labelling on units and the issuing of revised guidance.
If the LP15 defaulted to automatic mode or on start-up required, the choice of manual or automatic mode it is possible that such delays could be avoided.
I understand that procurement decisions regarding the future supply of defibrillators are imminent.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to activate the LP15 defibrillator in automatic mode
Wider context from the report “The LAS serious incident investigation identified a 4-minute delay between LP15 defibrillator pads being placed on Mr Marin’s chest and the administration of the first shock. During this period Mr Marin’s heart was in a shockable rhythm.
Paramedic A accepted that they had not reviewed the defibrillator as they were distracted by events.
Paramedic A did not activate the defibrillator in “automatic” mode. Had this setting been applied, any shockable rhythm would have been detected and an alert would have prompted the paramedic to shock to the patient.
This is not an isolated incident, the LAS conceded that it had undertaken a review of similar cases of delayed defibrillation. The review found that a factor was that the LP15 defibrillator model, defaults to manual mode requiring the user to switch to automatic mode before use.
2 studies cited by the LAS indicated that every minute a patient is delayed effective resuscitation; their prospects of survival diminishes by between 10-22%.
The LAS have introduced remedial measures to prevent such actions occurring, incorporating; training on the use of the LP15, labelling on units and the issuing of revised guidance.
If the LP15 defaulted to automatic mode or on start-up required, the choice of manual or automatic mode it is possible that such delays could be avoided.
I understand that procurement decisions regarding the future supply of defibrillators are imminent.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Professional organisations should determine appropriate defibrillator default settings according to local protocols, intended use and available guidance.
Verbatim wording from the response “Professional organisations are best placed to determine the appropriate default settings according to their local protocols and intended use, taking into account available guidance.” Source location 2020-0066-Response-from-Dept.-Health-and-Social-Care-Redacted
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 Changing the defibrillator default to AED mode is not practical for everyday use because the device also functions as a clinical monitoring tool.
Verbatim wording from the response “I understand that the London Ambulance Service has considered if changing the default setting of the LIFEPAK 15 to AED mode could improve clinical outcomes. The London Ambulance Service has decided, for reasons set out in its response to your report, that this is not practical for every-day use given the device’s functionality as both a clinical monitoring tool and defibrillator.” Source location 2020-0066-Response-from-Dept.-Health-and-Social-Care-Redacted
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 device's current manual default mode is considered acceptable based on the ambulance service's rationale, subject to monitoring for continuing delays.
Verbatim wording from the response “Finally, my officials have drawn this matter to the attention of the MHRA and also Professor ████████, the National Clinical Director for Heart Disease at NHSEI. Following discussion with clinical colleagues, Professor ████████ has advised that the current default mode of the device being manual, rather than automatic, is acceptable having considered the rationale of the London Ambulance Service deliberations on this matter. Professor ████████ has recommended that, if further monitoring and analysis of data shows continuing evidence of delays, consideration should be given to changing the default setting of the device and this advice has been shared with the London Ambulance Service.” Source location 2020-0066-Response-from-Dept.-Health-and-Social-Care-Redacted
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 Future defibrillator procurement is a matter for individual ambulance services.
Verbatim wording from the response “In relation to future procurement of defibrillators, this is a matter for individual ambulance services. I am advised that the London Ambulance Service is looking to source devices that have in-built technology to negate the need for the user to actively select the mode of operation. I understand that such a device has not been located but that, where it can, the London Ambulance Service is encouraging manufacturers to consider this functional requirement for future models.” Source location 2020-0066-Response-from-Dept.-Health-and-Social-Care-Redacted
Open published response
6 Mar 2020 Name not published · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to ensure timely and geographically consistent access to thrombectomy services View source Lack of public awareness of the risk of stroke arising from cocaine use View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Name not published · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
████████ ingested cocaine, suffered a basilar artery occlusion and posterior stroke, underwent thrombolysis and thrombectomy, and was declared brainstem dead on 13 June 2019. Concerns related to limited public awareness of the stroke risks associated with cocaine use and variation in access to thrombectomy services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely and geographically consistent access to thrombectomy services
Wider context from the report “2. I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing . I am concerned that this variation will mean that future deaths will occur in similar circumstances , unless access to thrombectomy services is improved .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 public awareness of the risk of stroke arising from cocaine use
Wider context from the report “1. ████████ family raised concerns that the risk of stroke arising from cocaine use was not known to him nor his family members . They were concerned that future deaths could occur in similar circumstances and that there is limited public awareness of such risks . I share these concerns and ask that Public Health England consider this point.
” Open source report
3 Mar 2020 Shaun Lea Turner · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Delays in accessing appropriate mental health services and receiving support View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Shaun Lea Turner · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Shaun Lea Turner was found unresponsive at home after ingesting a fatal amount of codeine. The inquest concluded that his death was suicide, with drug toxicity on a background of bronchopneumonia. His family raised concerns about delays in accessing appropriate mental health services and the effect of a missed call from those 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 Delays in accessing appropriate mental health services and receiving support
Wider context from the report “During the course of the inquest, evidence was given by Mr Turner's family that whilst they accepted that there had been attempted contact of him by mental health services he was worried about how long it would take him to be able to access appropriate mental health services and receive support . He was aware through previous contact with Mental Health services that there could be delays and when he missed a call from them, the impact of that in relation to accessing mental health services preyed on his mind .
” 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 Allocate national funding to transform urgent and emergency mental health care and provide alternative provision, including safe havens and crisis cafes.
Verbatim wording from the response “We recognise the need for people experiencing a mental health crisis to get the care that they need quickly. Every local health service has now signed up to having a round the clock community mental health crisis service by 2021, with people whose needs might be escalating to crisis point able to self-refer in the same way they can for urgent physical health care. More than £200million of national funding has been allocated to local areas to transform urgent and emergency mental health care and provide new, alternative forms of provision, such as safe havens and crisis cafes. An additional £140million will bolster these services further from 2021 onwards.” Source location 2020-0050-Response-from-the-Department-of-Health-and-Social-Care-1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional funding from 2021 to further strengthen urgent and emergency mental health crisis services.
Verbatim wording from the response “We recognise the need for people experiencing a mental health crisis to get the care that they need quickly. Every local health service has now signed up to having a round the clock community mental health crisis service by 2021, with people whose needs might be escalating to crisis point able to self-refer in the same way they can for urgent physical health care. More than £200million of national funding has been allocated to local areas to transform urgent and emergency mental health care and provide new, alternative forms of provision, such as safe havens and crisis cafes. An additional £140million will bolster these services further from 2021 onwards.” Source location 2020-0050-Response-from-the-Department-of-Health-and-Social-Care-1
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 Expand access to talking and psychological therapies through the Improving Access to Psychological Therapies programme.
Verbatim wording from the response “We are expanding access to talking and psychological therapies and improving quality through the Improving Access to Psychological Therapies (IAPT) programme¹. Already, over 1 million people a year are starting treatment and we are aiming to increase access to psychological therapies for an additional 600,000 people with common mental health problems each year by 2020/21. The NHS Long Term Plan² commits to ensuring that an additional 380,000 adults and older adults will be able to access NICE³-approved IAPT services by 2023/24.” Source location 2020-0050-Response-from-the-Department-of-Health-and-Social-Care-1
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 mental health access and waiting-time standards, including standards for early psychosis intervention and psychological therapies.
Verbatim wording from the response “We have introduced the first ever access and waiting time standards for mental health services, including standards for early intervention for people experiencing a first episode of psychosis and accessing psychological and talking therapies. These are being met or are on track for delivery. In addition, the NHS has committed to testing and rolling out comprehensive waiting time standards for adults and children over the next decade.” Source location 2020-0050-Response-from-the-Department-of-Health-and-Social-Care-1
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 Implement emergency mental health waiting-time targets from 2020/21, aligned with emergency physical-health targets.
Verbatim wording from the response “The NHS Long Term Plan also commits to specific waiting times targets for emergency mental health services which will take effect for the first time from 2020/21 onwards and will align with the equivalent targets for emergency physical health services.” Source location 2020-0050-Response-from-the-Department-of-Health-and-Social-Care-1
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 Establish round-the-clock community mental health crisis services in every local health service by 2021, with self-referral for escalating needs.
Verbatim wording from the response “We recognise the need for people experiencing a mental health crisis to get the care that they need quickly. Every local health service has now signed up to having a round the clock community mental health crisis service by 2021, with people whose needs might be escalating to crisis point able to self-refer in the same way they can for urgent physical health care. More than £200million of national funding has been allocated to local areas to transform urgent and emergency mental health care and provide new, alternative forms of provision, such as safe havens and crisis cafes. An additional £140million will bolster these services further from 2021 onwards.” Source location 2020-0050-Response-from-the-Department-of-Health-and-Social-Care-1
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 Test and roll out comprehensive adult and children’s mental health waiting-time standards.
Verbatim wording from the response “We have introduced the first ever access and waiting time standards for mental health services, including standards for early intervention for people experiencing a first episode of psychosis and accessing psychological and talking therapies. These are being met or are on track for delivery. In addition, the NHS has committed to testing and rolling out comprehensive waiting time standards for adults and children over the next decade.” Source location 2020-0050-Response-from-the-Department-of-Health-and-Social-Care-1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure additional adults and older adults can access NICE-approved Improving Access to Psychological Therapies services by 2023/24.
Verbatim wording from the response “We are expanding access to talking and psychological therapies and improving quality through the Improving Access to Psychological Therapies (IAPT) programme¹. Already, over 1 million people a year are starting treatment and we are aiming to increase access to psychological therapies for an additional 600,000 people with common mental health problems each year by 2020/21. The NHS Long Term Plan² commits to ensuring that an additional 380,000 adults and older adults will be able to access NICE³-approved IAPT services by 2023/24.” Source location 2020-0050-Response-from-the-Department-of-Health-and-Social-Care-1
Open published response
2 Mar 2020 HARRY RICHFORD · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 20 Lack of cross-site clinical working opportunities View source Failure to notify the Coroner of a child death View source Uncertain auditing and logging of neonatal resuscitation pro forma completion View source Unclear guidance for obtaining anaesthetic help in paediatric emergencies View source Failure to retain placentae for examination after severe foetal distress View source Lack of clear requirements for consultant assessment of locum competence before overnight responsibility View source Failure to produce timely and sufficiently detailed statements after deaths View source Failure to assess and supervise locum clinicians View source Lack of clarity about when to call a consultant at night View source Failure to record consultant telephone advice View source Failure to record feedback and audit locum recruitment View source Insufficient consultant availability for night-time emergencies View source Lack of staff knowledge of applicable clinical guidelines and policies View source Failure to share important independent safety reports with staff View source Lack of paediatric team knowledge of neonatal collapse guidelines View source Lack of clarity about prompt action in obstetric emergencies View source Substandard obstetric record keeping View source Inaccurate and incomplete child death notification forms View source Inadequate neonatal resuscitation training View source Inaccurate MBRRACE maternal and neonatal death reporting View source See 17 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
HARRY RICHFORD · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Harry Richford was born at QEQM on 2 November 2017 and died at William Harvey Hospital on 9 November 2017 after being transferred there. The report describes delays in delivery, shortcomings in the caesarean delivery and neonatal resuscitation, and subsequent hypoxia and brain injury. Substantive concerns included locum recruitment, assessment and supervision; clarity about escalation to consultants; neonatal resuscitation training; record keeping and adherence to guidelines; and inaccurate death notifications and reporting.
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 cross-site clinical working opportunities
Wider context from the report “Concern 8
Prior to Harry's death both ████████████████, a senior member of staff who had the care of Harry at the William Harvey Hospital, accepted that there were no opportunities for cross site working between QEQM and the William Harvey Hospital . Currently two out of eight middle grade doctors have had the opportunity to spend time at the William Harvey, which has a much higher specification neo natal unit. ████████ described the lack of opportunities before Harry's death as ‘at best, very surprising'.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 notify the Coroner of a child death
Wider context from the report “Concern 17
The child death notification form was incorrectly completed in that Harry's death was recorded as 'expected'. No notification was made to the Coroner . No details were filled in on the notification form giving any detail of the problems leading to Harry's death. As a result, the Child Death Overview Panel would have been unaware of the problems encountered and could not have shared learning to prevent other such deaths occurring. I make no recommendation in respect of the lack of notification to the Coroner as I am aware that the Senior Coroner has already dealt with this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Uncertain auditing and logging of neonatal resuscitation pro forma completion
Wider context from the report “Concern 15
The East Kent Trust should consider a review as to the use or otherwise of a resuscitation pro forma. A pro forma has since Harry's death been adopted by the East Kent Trust which, on the evidence of ████████, has improved the oversight of neo natal training and governance. It is not clear whether that pro forma is being audited or logged , or what actions are being done to ensure its completion and preservation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unclear guidance for obtaining anaesthetic help in paediatric emergencies
Wider context from the report “Concern 9
The resuscitation of Harry was eventually carried out by ████████, the anaesthetist looking after ████████. His evidence was that leaving his own patient to help the paediatric team was an unusual action to take in the UK although he had often performed such actions in Nepal. Doctors at QEQM indicated that there was an informal policy that if a middle grade paediatrician found themselves in an emergency, they could seek help from their anaesthetic colleagues . It was unclear whether the anaesthetists were aware of this informal policy . This informal policy should be clarified, and guidance given because there is a risk, that in an emergency, it will be overlooked .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 retain placentae for examination after severe foetal distress
Wider context from the report “Concern 12
The placenta of Harry was not retained . Examination of the placenta will in some circumstances assist in cases of severe foetal distress. The Royal College of Pathologists states that it is 'essential' for the placenta to be sent for examination in cases of severe foetal distress requiring admission to a neo natal unit.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clear requirements for consultant assessment of locum competence before overnight responsibility
Wider context from the report “Concern 2
The current policy of the East Kent Trust states that it is the responsibility of the healthcare professional who will be supervising the locum to assure themselves of his/her competence. This did not happen in this case. There is at present no requirement for a locum to be assessed on a day shift by a consultant before being left in charge overnight . There is no clear direction that it is the responsibility of the assessing consultant to satisfy themselves of the locum's experience and capability . One specialist from outside the East Kent Trust, ████████, also stated that it would assist the assessing consultants to be able to see not only the locum's CV but also their references and any training records available.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to produce timely and sufficiently detailed statements after deaths
Wider context from the report “Concern 16
In order to try to prevent future deaths it is important that there are clear records and statements made when a death occurs so that lessons can be learnt. In this instance many of the statements were very scanty in their content and some were made a long time after the event . In some instances, staff had to make statements from memory without the advantage of seeing the medical notes . Contemporaneous (or as near as possible) notes are also very much in the interests of the staff involved so that they can give clear accounts of their actions and reasons for them if required to do so at a later date.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 and supervise locum clinicians
Wider context from the report “Concern 1
████████ was recruited as a locum registrar by the Hospital Trust without there appearing to have been any assessment of his skills and abilities or any supervision of him at the hospital . This was not an emergency appointment after, for example, a doctor calling in sick at the last minute. ████████ gave evidence that the recruitment, assessment and supervision of locums is a national problem and that there is a need for a review on a national level. This raises concerns that there may be a risk to other lives both at this trust and at other trusts in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about when to call a consultant at night
Wider context from the report “Concern 5
There appeared to be from the evidence given at the inquest substantial confusion amongst staff as to when a consultant should be called at night . The East Kent Trust now has some 70 hours a week consultant attendance on the wards. That leaves 14 hours a day when there is no consultant present. Staff, whether doctors, nurses or midwives should know the circumstances in which consultant help should be sought and should not feel inhibited from making their views known. If staff are unaware or unsure of when the consultant should be called that potentially poses a continuing risk to 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 Failure to record consultant telephone advice
Wider context from the report “Concern 14
There are no current records kept by consultants who are telephoned at home for advice . In this case there was a dispute about the number of calls made to ████████ and as to the content of these calls. The advice given and the actions taken as a result are important for the preservation of 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 Failure to record feedback and audit locum recruitment
Wider context from the report “Concern 3
████████ had worked two night time shifts at the QEQM before the night of Harry's birth. The extent to which there was any feedback from the consultants on call those two nights to ████████ is unclear. She, erroneously, believed the East Kent Trust had employed ████████. There is no record of any written feedback . From the evidence of the medical director of the East Kent Trust it appears that the current locum recruitment policy is not being checked or audited . There is a potential for further risks to life arising from these shortfalls.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 consultant availability for night-time emergencies
Wider context from the report “Concern 6
The current contracts at the East Kent Trust permit consultants to live up to 30 minutes travel time from the hospital . This poses considerable problems and risks for night time emergencies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 applicable clinical guidelines and policies
Wider context from the report “Concern 10
There appeared to be considerable confusion among members of staff as to which, if any, guidelines and policies affected them . While two senior members of staff, ████████████████ (consultant), said that the East Kent Trust has systems in place to ensure knowledge of and compliance with Trust policies neither of them was able to say whether this was effective. Significant issues remain as to the knowledge of staff as to which guidelines govern their behaviour (this was also a finding of the Health and Safety Investigation Board in 2019). Such confusion or lack of knowledge increases the 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 Failure to share important independent safety reports with staff
Wider context from the report “Concern 19
Important independent reports do not appear to have been shared within the East Kent Trust's staff , for instance the HSIB report into Harry's death appeared during the inquest to be unknown to a number of the staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of paediatric team knowledge of neonatal collapse guidelines
Wider context from the report “Concern 11
There was a lack of knowledge within the paediatric team of guidelines issued by the Department of Women's Health . The evidence from the East Kent Trust doctors was that the guidelines issued by the department directed to 'all maternity and neonatal staff who may be involved with the immediate care and support of a collapsed neonate' would not have been known to the paediatric team at the relevant time. Even senior clinicians, such as ████████, were not aware of the relevant guidelines.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about prompt action in obstetric emergencies
Wider context from the report “Concern 4
There is a risk to the life of both mothers and babies if there is a lack of clarity as to the processes or the need to take prompt action where it is necessitated in the event of an obstetric concern or emergency developing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Substandard obstetric record keeping
Wider context from the report “Concern 13
The standard of record keeping on the obstetric unit was substantially sub-standard . The quality of the note taking and records is of considerable importance to new staff taking over responsibility for mother and baby. Without there being clear accurate records there is a risk of further mistakes being made leading, at the worst, to the risk of death. An example of this in Harry's case is that the record of the syntocinon prescribed to ████████ over a long period of time is inconsistent with the evidence of the midwives and the registrar who gave it to her.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inaccurate and incomplete child death notification forms
Wider context from the report “Concern 17
The child death notification form was incorrectly completed in that Harry's death was recorded as 'expected' . No notification was made to the Coroner. No details were filled in on the notification form giving any detail of the problems leading to Harry's death . As a result, the Child Death Overview Panel would have been unaware of the problems encountered and could not have shared learning to prevent other such deaths occurring. I make no recommendation in respect of the lack of notification to the Coroner as I am aware that the Senior Coroner has already dealt with this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate neonatal resuscitation training
Wider context from the report “Concern 7
The evidence of ████████ raised substantial concerns about the quality of training and learning in respect of neonatal resuscitation at the East Kent Trust. His evidence was that it would be desirable for middle grade doctors to attend the ARNI course (the advanced resuscitation of the new born infant). He also recommended that there should be simulated drills in neo natal resuscitation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inaccurate MBRRACE maternal and neonatal death reporting
Wider context from the report “Concern 18
The MBRRACE form in respect of Harry Richford was inaccurate in a number of important areas . The form is important to provide robust national data to support the delivery of safe, high quality maternal and new born care as well as identifying errors and faults, if any, where there has been a maternal or infant death so that future deaths can be avoided.
” 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 is responsible for setting out and implementing actions to address the identified maternity-service safety risks.
Verbatim wording from the response “I am advised that the Trust Board is taking these matters very seriously and has welcomed the national support being provided. I expect the Trust to set out in its response to your report the actions it is taking to address the important safety risks you have outlined.” 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 CQC is responsible for deciding and providing further detail on regulatory action concerning the Trust’s maternity-service safety risks.
Verbatim wording from the response “In February, the Care Quality Commission (CQC) conducted an unannounced inspection of the Trust’s maternity services, after which it wrote to the Trust with an overview of its findings and sought assurance on matters relating to triage, day care and medical staffing. The full report of the CQC’s inspection will be published in due course. However, I want to assure you that the CQC continues to be in close contact with the Trust and will take regulatory action if it decides this is necessary. You have issued your report to the CQC and I expect the CQC to provide further detail on its actions.” Source location Response from Department of Health and Social Care
Open published response
27 Feb 2020 Mr Mohan Acharya · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1 Emergency department overcrowding 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
Mr Mohan Acharya · 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 Mohan Acharya died at Northampton General Hospital on 8 March 2018 from bronchopneumonia causing sepsis or infection, hypovolemia and cardiac arrest. The report raised concerns about emergency department crowding, which is associated with increased mortality among admitted patients and was reported to cause approximately 500 deaths per year.
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 Emergency department overcrowding
Wider context from the report “According to the Royal College of Emergency Medicine:-
1. Emergency department crowding is associated with increased mortality amongst admitted patients ; and
2. Approximately 500 deaths per year are caused by overcrowded Emergency Departments .
” 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 £145 million in capital funding for winter hospital improvements, including upgraded wards and redeveloped emergency departments.
Verbatim wording from the response “Winter is a particularly demanding time for the NHS and therefore, in 2019, the Government provided £145 million in capital funding to help winter improvements in hospitals. This included upgraded wards and re-developed A&E departments that the NHS expected would bring the equivalent of an additional 900 beds.” Source location 2020-0045-Response-from-the-Department-of-Health-and-Social-Care
Open published response
Concerns raised 2 Lack of national guidance on managing and reducing pressure-ulcer risks in Emergency Departments View source Failure of Trust policies to recognise and respond appropriately to pressure-ulcer risk during prolonged Emergency Department stays 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
Beryl Holland · 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
Beryl Holland sustained a fractured neck of femur after a fall at the care home where she resided, underwent surgery at Stepping Hill Hospital, continued to decline post-operatively, and died there on 7 July 2019. The concerns related to her prolonged stay in the Emergency Department while awaiting a ward bed, her vulnerability to pressure ulcers, and the absence of national guidance for managing pressure-ulcer risks in Emergency Department settings.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on managing and reducing pressure-ulcer risks in Emergency Departments
Wider context from the report “The inquest heard that Beryl Holland was in the Emergency Department of the Acute Hospital for a significant period of time before ultimately been transferred to a ward. This was due to awaiting a suitable bed. She was vulnerable and at high risk of developing pressure ulcers. The trust in question had identified gaps in its processes and taken steps to reduce the risk of pressure ulcers developing/worsening in the Emergency Department. The inquest was told that there is no national guidance relating to the management of/reducing the risks of pressure ulcers developing in an Emergency Department setting . As a result, Trusts will develop their own policies, which may not always recognise and react appropriately to the level of risk faced by those at risk of pressure ulcers particularly where there are prolonged periods of time in the Emergency Department.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of Trust policies to recognise and respond appropriately to pressure-ulcer risk during prolonged Emergency Department stays
Wider context from the report “The inquest heard that Beryl Holland was in the Emergency Department of the Acute Hospital for a significant period of time before ultimately been transferred to a ward. This was due to awaiting a suitable bed. She was vulnerable and at high risk of developing pressure ulcers. The trust in question had identified gaps in its processes and taken steps to reduce the risk of pressure ulcers developing/worsening in the Emergency Department. The inquest was told that there is no national guidance relating to the management of/reducing the risks of pressure ulcers developing in an Emergency Department setting. As a result, Trusts will develop their own policies, which may not always recognise and react appropriately to the level of risk faced by those at risk of pressure ulcers particularly where there are prolonged periods of time in the Emergency Department .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing NICE guidance, local NHS policies and the emergency department safety checklist provide relevant arrangements for preventing and managing pressure ulcers.
Verbatim wording from the response “I am aware that the National Institute for Health and Care Excellence (NICE) has advised you in its response that a clinical guideline is available on the Prevention and Management of Pressure Sores (CG179)¹ and that this guideline provides specific recommendations to clinicians in relation to patients receiving care in emergency department settings if they have a risk factor. It is the view of NICE that this guideline provides relevant guidance.” Source location 2020-0037-Response-from-the-Department-for-Health-and-Social-Care
Open published response
Concerns raised 4 Oxygen-saturation monitoring failing to detect deterioration when oxygen levels do not deplete View source Inadequate treatment of total body potassium depletion with gastroenteritis resuscitation View source Failure to recognise total body potassium depletion in unwell children with myopathies View source Atypical presentation of respiratory distress in children with myopathies weakened by low potassium 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
LUKE OWEN JACKSON · 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
Luke Owen Jackson, who had Becker’s Muscular Dystrophy and a chest infection, was admitted to hospital on 4 December 2019 and suffered a cardiac arrest on 6 December before being transferred to the Evelina Children’s Hospital. He later died on palliative care from hypoxic ischaemic encephalopathy following prolonged cardiac arrest. The principal concerns included recognition and treatment of total-body potassium depletion in a child with myopathy, and the limitations of monitoring oxygen saturation when assessing deterioration.
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 Oxygen-saturation monitoring failing to detect deterioration when oxygen levels do not deplete
Wider context from the report “The Trust has taken action to address the conclusions of its Root Cause Analysis and has learned and disseminated lessons, improving its processes. This Report is made to assist learning in the public interest as evidence was heard from a consultant from a specialist children’s hospital that total body potassium depletion is not always recognised in children with myopathies who become unwell. They may present with diarrhoea and vomiting due to shunting of the blood away from the gut to protect vital organs such as the brain and heart.
(1) Luke had complex needs and was awaiting results of genetic testing confirmed as Becker’s Muscular Dystrophy. He had not been eating and drinking, had loose stools and vomiting that had progressed over a five-day period in a background of a chest infection. His parents had sought and followed medical advice from the hospital by telephone. Luke continued to deteriorate, and he was admitted. The Trust took some steps on admission to address his low potassium.
(2) Evidence was heard from a Consultant from the Evelina Children’s Hospital that they get almost 2000 referrals a year and many have diarrhoea and vomiting as a first symptom. Issues relating to metabolic derangement in a child with myopathies is not always recognised as total body potassium depletion and that treatment may need to be undertaken in intensive care due to the increased amounts of potassium required to correct the derangement and manage clinical risks:
(i) Children with Myopathies - have low muscle mass that compromises their ability to correct their own potassium levels when unwell.
(ii) Luke had a chest infection, however his low potassium made him weaker and as it progressed, he was shunting blood away from his gut to compensate (this assists to protect the vital organs such as the heart and brain) which resulted in loose stools and vomiting; this was not a consequence of gastroenteritis. One of the early symptoms of this shunting process is a high heart rate.
(iii) A bolus of potassium and fluid resuscitation to treat gastroenteritis was not sufficient to treat total body potassium depletion which requires a central line with significant potassium replacement in intensive care to manage clinical risk.
(iv) Development of a chest infection requires a child to breath harder and this becomes more difficult in a child with myopathies that is already weakened due to low potassium and will not present with the usual symptoms of respiratory distress.
(v) As Luke was treated with oxygen therapy, the monitor alarm set for oxygen saturations did not sound as his oxygen did not deplete and he went into cardiac arrest
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 treatment of total body potassium depletion with gastroenteritis resuscitation
Wider context from the report “The Trust has taken action to address the conclusions of its Root Cause Analysis and has learned and disseminated lessons, improving its processes. This Report is made to assist learning in the public interest as evidence was heard from a consultant from a specialist children’s hospital that total body potassium depletion is not always recognised in children with myopathies who become unwell. They may present with diarrhoea and vomiting due to shunting of the blood away from the gut to protect vital organs such as the brain and heart.
(1) Luke had complex needs and was awaiting results of genetic testing confirmed as Becker’s Muscular Dystrophy. He had not been eating and drinking, had loose stools and vomiting that had progressed over a five-day period in a background of a chest infection. His parents had sought and followed medical advice from the hospital by telephone. Luke continued to deteriorate, and he was admitted. The Trust took some steps on admission to address his low potassium.
(2) Evidence was heard from a Consultant from the Evelina Children’s Hospital that they get almost 2000 referrals a year and many have diarrhoea and vomiting as a first symptom. Issues relating to metabolic derangement in a child with myopathies is not always recognised as total body potassium depletion and that treatment may need to be undertaken in intensive care due to the increased amounts of potassium required to correct the derangement and manage clinical risks :
(i) Children with Myopathies - have low muscle mass that compromises their ability to correct their own potassium levels when unwell.
(ii) Luke had a chest infection, however his low potassium made him weaker and as it progressed, he was shunting blood away from his gut to compensate (this assists to protect the vital organs such as the heart and brain) which resulted in loose stools and vomiting; this was not a consequence of gastroenteritis. One of the early symptoms of this shunting process is a high heart rate.
(iii) A bolus of potassium and fluid resuscitation to treat gastroenteritis was not sufficient to treat total body potassium depletion which requires a central line with significant potassium replacement in intensive care to manage clinical risk .
(iv) Development of a chest infection requires a child to breath harder and this becomes more difficult in a child with myopathies that is already weakened due to low potassium and will not present with the usual symptoms of respiratory distress.
(v) As Luke was treated with oxygen therapy, the monitor alarm set for oxygen saturations did not sound as his oxygen did not deplete and he went into cardiac arrest
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 total body potassium depletion in unwell children with myopathies
Wider context from the report “The Trust has taken action to address the conclusions of its Root Cause Analysis and has learned and disseminated lessons, improving its processes. This Report is made to assist learning in the public interest as evidence was heard from a consultant from a specialist children’s hospital that total body potassium depletion is not always recognised in children with myopathies who become unwell . They may present with diarrhoea and vomiting due to shunting of the blood away from the gut to protect vital organs such as the brain and heart.
(1) Luke had complex needs and was awaiting results of genetic testing confirmed as Becker’s Muscular Dystrophy. He had not been eating and drinking, had loose stools and vomiting that had progressed over a five-day period in a background of a chest infection. His parents had sought and followed medical advice from the hospital by telephone. Luke continued to deteriorate, and he was admitted. The Trust took some steps on admission to address his low potassium.
(2) Evidence was heard from a Consultant from the Evelina Children’s Hospital that they get almost 2000 referrals a year and many have diarrhoea and vomiting as a first symptom. Issues relating to metabolic derangement in a child with myopathies is not always recognised as total body potassium depletion and that treatment may need to be undertaken in intensive care due to the increased amounts of potassium required to correct the derangement and manage clinical risks:
(i) Children with Myopathies - have low muscle mass that compromises their ability to correct their own potassium levels when unwell.
(ii) Luke had a chest infection, however his low potassium made him weaker and as it progressed, he was shunting blood away from his gut to compensate (this assists to protect the vital organs such as the heart and brain) which resulted in loose stools and vomiting; this was not a consequence of gastroenteritis. One of the early symptoms of this shunting process is a high heart rate.
(iii) A bolus of potassium and fluid resuscitation to treat gastroenteritis was not sufficient to treat total body potassium depletion which requires a central line with significant potassium replacement in intensive care to manage clinical risk.
(iv) Development of a chest infection requires a child to breath harder and this becomes more difficult in a child with myopathies that is already weakened due to low potassium and will not present with the usual symptoms of respiratory distress.
(v) As Luke was treated with oxygen therapy, the monitor alarm set for oxygen saturations did not sound as his oxygen did not deplete and he went into cardiac arrest
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Atypical presentation of respiratory distress in children with myopathies weakened by low potassium
Wider context from the report “The Trust has taken action to address the conclusions of its Root Cause Analysis and has learned and disseminated lessons, improving its processes. This Report is made to assist learning in the public interest as evidence was heard from a consultant from a specialist children’s hospital that total body potassium depletion is not always recognised in children with myopathies who become unwell. They may present with diarrhoea and vomiting due to shunting of the blood away from the gut to protect vital organs such as the brain and heart.
(1) Luke had complex needs and was awaiting results of genetic testing confirmed as Becker’s Muscular Dystrophy. He had not been eating and drinking, had loose stools and vomiting that had progressed over a five-day period in a background of a chest infection. His parents had sought and followed medical advice from the hospital by telephone. Luke continued to deteriorate, and he was admitted. The Trust took some steps on admission to address his low potassium.
(2) Evidence was heard from a Consultant from the Evelina Children’s Hospital that they get almost 2000 referrals a year and many have diarrhoea and vomiting as a first symptom. Issues relating to metabolic derangement in a child with myopathies is not always recognised as total body potassium depletion and that treatment may need to be undertaken in intensive care due to the increased amounts of potassium required to correct the derangement and manage clinical risks:
(i) Children with Myopathies - have low muscle mass that compromises their ability to correct their own potassium levels when unwell.
(ii) Luke had a chest infection, however his low potassium made him weaker and as it progressed, he was shunting blood away from his gut to compensate (this assists to protect the vital organs such as the heart and brain) which resulted in loose stools and vomiting; this was not a consequence of gastroenteritis. One of the early symptoms of this shunting process is a high heart rate.
(iii) A bolus of potassium and fluid resuscitation to treat gastroenteritis was not sufficient to treat total body potassium depletion which requires a central line with significant potassium replacement in intensive care to manage clinical risk.
(iv) Development of a chest infection requires a child to breath harder and this becomes more difficult in a child with myopathies that is already weakened due to low potassium and will not present with the usual symptoms of respiratory distress .
(v) As Luke was treated with oxygen therapy, the monitor alarm set for oxygen saturations did not sound as his oxygen did not deplete and he went into cardiac arrest
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NICE considers existing general guidance on assessment, monitoring, and altering care as indicated appropriate.
Verbatim wording from the response “It is the view of NICE that the current general guidance about assessment, monitoring, and altering care as indicated is appropriate.” Source location 2021-0052-Response-from-Dept-of-Health-and-Social-Care-Redacted
Open published response
30 Jan 2020 Julie Sandra O'Connor · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure to accurately report smear test results View source Failure to recognise and appropriately assess an abnormal cervix 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
Julie Sandra O'Connor · 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
Julie Sandra O'Connor had a smear test in September 2014 that was reported as normal when it was not, and her cervical cancer was not diagnosed during examinations in August and November 2016. She was diagnosed and treated in March 2017, but her condition deteriorated and she died from metastatic squamous cell carcinoma of the cervix. The report identified concerns about the incorrect smear result and failures to recognise the cancer or the need for further assessment on several occasions.
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 accurately report smear test results
Wider context from the report “In this case as well as the fact that the smear test was incorrectly reported there were also 2 occasions when there was a failure to recognise a clinically obvious cancer of the cervix or a failure to recognise a need for further assessment in August and November 2016. In addition the evidence of the experts was that the abnormal appearance of the cervix should also have been diagnosed in February 2017.
The North Bristol NHS Trust have developed a guide for “the management of abnormal cervix, ectropian, and post coital bleeding”* and it is the view of the trust that if this guide had been in place at the time that Julie’s medical condition would have been picked up earlier.
*I attach a copy of the guide produced by 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 Failure to recognise and appropriately assess an abnormal cervix
Wider context from the report “In this case as well as the fact that the smear test was incorrectly reported there were also 2 occasions when there was a failure to recognise a clinically obvious cancer of the cervix or a failure to recognise a need for further assessment in August and November 2016. In addition the evidence of the experts was that the abnormal appearance of the cervix should also have been diagnosed in February 2017.
The North Bristol NHS Trust have developed a guide for “the management of abnormal cervix, ectropian, and post coital bleeding”* and it is the view of the trust that if this guide had been in place at the time that Julie’s medical condition would have been picked up earlier.
*I attach a copy of the guide produced by the Trust.
” Open source report
29 Jan 2020 Thiago Araujo · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Lack of support or education for families and carers managing emotionally unstable personality disorder View source Failure to make arrangements to address risks when closing crisis team referrals View source Lack of a process for families to escalate concerns to prevent delivery of hazardous packages View source Failure to inform families about the facility for reopening crisis team support View source Delays of 14 days in securing mental health act assessments View source Failure to act on an inpatient admission plan following identification of acute suicide risk View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Thiago Araujo · 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
Thiago Araujo was found deceased at his mother’s shared address on 5 February 2020 after deliberately ingesting a substance. He had been receiving community psychiatric care and had disengaged from crisis-team support. Concerns included the closure of his crisis-team referral without arrangements to address identified risks, inaction after an acute suicide risk was identified, and the lack of a process for his family to escalate concerns about delivery of a potentially harmful package.
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 support or education for families and carers managing emotionally unstable personality disorder
Wider context from the report “3. Family and carers of patients diagnosed with emotionally unstable personality disorder do not receive support or education upon management of this diagnosis from Camden and Islington NHS Trust, unless the patient has been received for treatment by the personality disorder service .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 arrangements to address risks when closing crisis team referrals
Wider context from the report “1. On 24 January 2020 Mr Araujo had discharged himself from psychiatric inpatient care he was to be supervised by the Camden and Islington NHS trust crisis team. Mr Araujo failed to engage with the crisis team and following a meeting on 30 January 2020 the crisis team closed Mr Araujo’s referral . In the course of this closure no arrangements were made to address the risks presented by Mr Araujo .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 process for families to escalate concerns to prevent delivery of hazardous packages
Wider context from the report “6. In the days leading to Mr Araujo’s death his family became aware that he had made an online purchase of ████████ which was to be delivered to his father’s home address. Despite raising these issues with Camden and Islington NHS trust, the Metropolitan police and employees of the post office there appeared to be no process available to the family to escalate their concerns to prevent delivery of this package .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 inform families about the facility for reopening crisis team support
Wider context from the report “2. Following Mr Araujo’s death it has become clear that the closure of his case by the crisis team was not permanent, and had Mr Araujo or his family approached the crisis team to reopen his case, steps could have been taken to reinstate crisis team support . Mr Araujo’s family were unaware of this facility .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 of 14 days in securing mental health act assessments
Wider context from the report “5. In evidence the community recovery team indicated that a factor in their inaction was the knowledge that arranging a section 135 mental health act 1983 warrant assessment would take two weeks . Such an assessment requires actions by an approved mental health practitioner from the local authority, two section 12 mental health act approved doctors, the assistance of the Metropolitan police and the local magistrates court to secure a warrant. A delay of 14 days in securing a mental health act assessment is in my opinion unacceptable .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 act on an inpatient admission plan following identification of acute suicide risk
Wider context from the report “4. By 4 February 2020 the Camden and Islington community recovery team identified an acute risk of suicide in Mr Araujo, faced with his non-compliance with community treatment they considered an admission into inpatient care . No actions were taken to affect this plan .
” 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 Operate a multi-agency process with stakeholders and Government to identify emerging suicide methods and develop measures to restrict access, remove promotional material and improve risk warnings.
Verbatim wording from the response “On the wider matters of your report, you may wish to note that we are working with a broad range of stakeholders to tackle emerging suicide methods, including the use of chemicals such as Mr Araujo took, and a process has been established with a range of stakeholders and across Government to rapidly flag emerging methods and take actions through a multi-agency approach. This includes but is not limited to, limiting access to the method, reducing or removing material that promotes its use as a method of suicide, and providing clearer warnings of risk.” Source location 2021-0132-Response-from-Dept.-of-Health-and-Social-Care-Redacted.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing Home Office guidance, supplier safeguards and online marketplace policies are relied on to address chemical sales and suicide-method access.
Verbatim wording from the response “Officials are informed through these meetings that the chemical used in this case is covered by existing guidance from the Home Office on the sale of explosives precursors and poisons. The Home Office regularly engages with suppliers of such chemicals to provide detailed guidance in relation to any additional safeguarding steps they may wish to take. Generally, online marketplaces maintain their own policies on prohibited items, many of which will include a prohibition on the sale of poisons. It is the seller’s obligation to check that items they are listing are permitted by their own policies and to take any action where it is appropriate.” Source location 2021-0132-Response-from-Dept.-of-Health-and-Social-Care-Redacted.pdf
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 organisations, including police, local authorities and NHS services, are responsible for systems ensuring Section 135 actions occur swiftly.
Verbatim wording from the response “In relation to the concerns you raise about the use of Section 135(1) of the Mental Health Act, it is not clear from your report whether the delay professionals expected lay in the magistrate issuing a Section 135(1) warrant; in securing an approved mental health practitioner and a doctor to be present when the officer actions the warrant; or in securing two doctors to carry out an assessment under the Act after the patient has been taken to hospital. However, we expect local organisations, including the police, local authority services, and the NHS, to have robust systems and agreements in place to ensure these actions are carried out swiftly.” Source location 2021-0132-Response-from-Dept.-of-Health-and-Social-Care-Redacted.pdf
Open published response
27 Jan 2020 Shanté Andrée Marie TURAY-THOMAS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 21 Provision of incorrect advice that an adrenaline auto injector switch is only a brand substitution View source Failure to reconsider adrenaline auto injector dose after switching device View source Inadequate and incorrect national training content for 111 call handlers on adrenaline auto injectors View source Failure to identify patients at particularly high risk from allergies and asthma View source Lack of named accountability for allergy services and provision View source Failure to assess patients’ access to and understanding of adrenaline auto injector advice View source Failure of the Adastra system to update location information across screens in real time View source Failure to establish whether specialist allergy care was being provided View source Inconsistency in anaphylaxis ambulance categorisation between 999 and 111 services View source Failure to explain the need for sequential administration of two adrenaline auto injectors in acute anaphylaxis View source Failure of 111 call audits to identify all significant call-handling failings View source Rare provision of practical placebo-device adrenaline auto injector training View source Failure to provide healthcare-professional training after an adrenaline auto injector switch View source Failure to communicate device-specific training requirements for adrenaline auto injectors View source Failure of NHS Digital to retain and act on previously identified call-handling safety issues View source Failure of AAI leaflets to specify the need for device-specific healthcare-professional training View source Failure of the 999 service to safety-net inappropriate 111 categorisation View source Single-sale availability of Emerade adrenaline auto injectors View source Failure to record and emphasise the need to carry two adrenaline auto injector pens View source Failure to advise prescribers to reconsider adrenaline auto injector dose after a device switch View source Failure to display the advice to carry two adrenaline auto injectors on the outside of the box View source See 18 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
Shanté Andrée Marie TURAY-THOMAS · 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
Shanté Andrée Marie Turay-Thomas ate hazelnuts on 18 September 2018 and died soon afterwards from acute anaphylaxis. The report identifies concerns about inadequate allergy care, advice and training concerning adrenaline auto-injectors, prescribing and clinical communication, and errors in the NHS 111 response and ambulance categorisation.
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 Provision of incorrect advice that an adrenaline auto injector switch is only a brand substitution
Wider context from the report “7. The GPs relied upon the advice given by Enfield Clinical Commissioning Group (CCG) that the scriptswitch was simply the replacement of one branded product with another branded product of the same drug/device . This gave false reassurance. The CCG joint formulary committee introduced a new drug for GPs, but then gave the wrong advice to accompany this .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to reconsider adrenaline auto injector dose after switching device
Wider context from the report “5. When Shanté’s AAI was changed from an EpiPen to an Emerade, her GPs failed to reconsider the prescription and to increase her dose from 300mgs to 500mcgs .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 and incorrect national training content for 111 call handlers on adrenaline auto injectors
Wider context from the report “17. In terms of national training for 111 call handlers, the NHS Digital distance learning pack contains advice that is in part inadequate and in part wrong . It does not give the crucial information that one dose of adrenaline, by whichever device it is administered, is very unlikely to be sufficient in the case of acute anaphylaxis . It contains a photograph to illustrate the use of an AAI, but in the photograph the device is held incorrectly .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 patients at particularly high risk from allergies and asthma
Wider context from the report “1. At the time of her death, Shanté was not receiving specialist care for her allergies. However, her general practitioners (GPs) failed to appreciate this. They assumed that she was being treated for her allergies at the transitional asthma clinic to which she had been referred following her paediatric discharge. This was an incorrect assumption.
The GPs had not identified Shanté (who had a high BMI and was severely allergic) as being at particularly high risk from her allergies and asthma, and had no awareness that they were the sole providers of Shanté’s allergy care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of named accountability for allergy services and provision
Wider context from the report “20. The issues within this prevention of future deaths report are predominantly national issues, but I heard at inquest that there is no person with named accountability for allergy services and allergy provision at NHS England or the Department of Health as a whole .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to assess patients’ access to and understanding of adrenaline auto injector advice
Wider context from the report “2. Shanté’s GPs knew that she should carry two adrenaline auto injector (AAI) pens at all times, and they may have mentioned this to her, but they failed to record this and they did not emphasise it to her.
They failed to emphasise to Shanté and her family that the reason for carrying two pens is primarily because in the event of severe acute anaphylaxis, the very strong likelihood is that both pens will need to be administered, one five minutes after the other, to keep the patient alive until the arrival of an emergency ambulance.
The GPs did not explore with Shanté the reason for her erratic requests for a pen . They did not explore with her where she kept her pens . They did not test her understanding of medical advice .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Adastra system to update location information across screens in real time
Wider context from the report “14. When Shanté became ill following the ingestion of nuts, her mother rang NHS 111 and got through to the London Central & West (LCW) service. However, the call handler incorrectly recorded Shanté’s location: he failed to untick a box and so her grandmother’s address was recorded as her location, rather than her mother’s address where she was staying at the time.
In an example of good practice, this error was recognised by the clinician who later took over the call. However, what nobody at LCW realised was that the Adastra computer system would not then update in real time for any screens save that of the particular clinician inputting the information .
The staff at LCW have since been made aware of this and have been trained to walk over and look at the primary screen to check the address, but it is not clear to me that there is now a national understanding of that element of the system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to establish whether specialist allergy care was being provided
Wider context from the report “1. At the time of her death, Shanté was not receiving specialist care for her allergies. However, her general practitioners (GPs) failed to appreciate this . They assumed that she was being treated for her allergies at the transitional asthma clinic to which she had been referred following her paediatric discharge. This was an incorrect assumption.
The GPs had not identified Shanté (who had a high BMI and was severely allergic) as being at particularly high risk from her allergies and asthma, and had no awareness that they were the sole providers of Shanté’s allergy care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistency in anaphylaxis ambulance categorisation between 999 and 111 services
Wider context from the report “16. The individuals making these errors were working within the context of NHS Digital’s categorisation of anaphylaxis as needing a category 2 ambulance rather than a category 1 ambulance, on the Adastra computer system that supports the LCW 111 service.
This was the wrong categorisation and not the categorisation that the call would have received if 999 had been called and the London Ambulance Service contacted in the first instance. Acute anaphylaxis is immediately life threatening and must be treated as a category 1.
I heard at inquest that NHS Digital has since changed its categorisation. However, I also heard that for those areas (I think approximately half the country, though this is not completely clear to me), where the 999 service and the 111 service are supported by different computer systems rather than the same system being common to both services, there could remain inconsistencies of categorisation between 999 and 111 .
Even where there are inconsistencies in categorisation, the 999 service will not re-categorise following a 111 clinician’s categorisation, unless a 999 clinician has spoken to the patient, so inappropriate 111 categorisation will not be safety netted by the 999 service. This must be recognised and factored in.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 explain the need for sequential administration of two adrenaline auto injectors in acute anaphylaxis
Wider context from the report “2. Shanté’s GPs knew that she should carry two adrenaline auto injector (AAI) pens at all times, and they may have mentioned this to her, but they failed to record this and they did not emphasise it to her.
They failed to emphasise to Shanté and her family that the reason for carrying two pens is primarily because in the event of severe acute anaphylaxis, the very strong likelihood is that both pens will need to be administered, one five minutes after the other , to keep the patient alive until the arrival of an emergency ambulance.
The GPs did not explore with Shanté the reason for her erratic requests for a pen. They did not explore with her where she kept her pens. They did not test her understanding of medical advice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 111 call audits to identify all significant call-handling failings
Wider context from the report “15. During the course of the 111 call, a number of errors were made. These were the errors of LCW individuals. When LCW audited the call in the first instance, the audit identified the problem with the address, but failed to recognise how badly the call had gone in other ways . Without effective audit and recognition of failings, it is difficult to see how there can be effective improvement .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Rare provision of practical placebo-device adrenaline auto injector training
Wider context from the report “13. I heard that the gold standard of training for use of any AAI is to give the patient the relevant pen (whichever that patient is prescribed) containing a placebo rather than adrenaline and, following appropriate instruction, ask the patient actually to administer a dose.
I heard at inquest that the incidence of this standard of training (in any setting) is rare . That may be for good reasons, but it seems that revisiting best practice training at a national level would be helpful.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 healthcare-professional training after an adrenaline auto injector switch
Wider context from the report “6. Following the scriptswitch, the GPs failed to ask Shanté to come in to the surgery for training in use of the Emerade . This would also have presented an ideal opportunity to explore Shanté’s understanding of the use of her pens and to ensure that she understood she needed to carry two at all times.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 communicate device-specific training requirements for adrenaline auto injectors
Wider context from the report “9. The CCG failed to inform prescribers that the Emerade pen requires different training to the EpiPen because different AAIs do not operate in the same way. In fact, the CCG gave the opposite advice .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 NHS Digital to retain and act on previously identified call-handling safety issues
Wider context from the report “19. One of the errors made by the first 111 call handler was a failure to ask to speak direct to the patient. This was the error of an individual.
However, this is not the first time that the issue has been brought to the attention of NHS Digital. At inquest, I asked the witness who appeared on behalf of NHS Digital, and indeed had been chosen by NHS Digital as the person best able to assist the court, if this had been an issue in the past. He said no. However, on 18 December 2018, Peter Harrowing, HM Assistant Coroner for Avon, sent a prevention of future deaths report to NHS Digital following the inquest touching the death of David Longden.
It was only when I asked the witness appearing on behalf of NHS Digital specifically about Coroner Harrowing’s report in respect of Mr Longden, pointing out that Coroner Harrowing had raised the need for NHS Digital to place greater emphasis on the call handler speaking to the patient, that the witness remembered that he had indeed seen that report.
I choose to characterise this as a memory lapse rather than as an intention wilfully to mislead the court. (A witness who lies whilst giving evidence on oath at inquest may be found in contempt of court and may even be prosecuted for the crime of perjury.) Nevertheless, if NHS Digital does not have a grasp of this sort of detail, specifically brought to its attention by a coroner in a prevention of future deaths report, it is difficult to see how there can be effective improvement .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 AAI leaflets to specify the need for device-specific healthcare-professional training
Wider context from the report “12. The Emerade AAI (and I assume the EpiPen and JEXT) leaflet does not specifically advise that training from a healthcare professional is needed in how to use this particular AAI as opposed to any other .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 999 service to safety-net inappropriate 111 categorisation
Wider context from the report “16. The individuals making these errors were working within the context of NHS Digital’s categorisation of anaphylaxis as needing a category 2 ambulance rather than a category 1 ambulance, on the Adastra computer system that supports the LCW 111 service.
This was the wrong categorisation and not the categorisation that the call would have received if 999 had been called and the London Ambulance Service contacted in the first instance. Acute anaphylaxis is immediately life threatening and must be treated as a category 1.
I heard at inquest that NHS Digital has since changed its categorisation. However, I also heard that for those areas (I think approximately half the country, though this is not completely clear to me), where the 999 service and the 111 service are supported by different computer systems rather than the same system being common to both services, there could remain inconsistencies of categorisation between 999 and 111.
Even where there are inconsistencies in categorisation, the 999 service will not re-categorise following a 111 clinician’s categorisation, unless a 999 clinician has spoken to the patient , so inappropriate 111 categorisation will not be safety netted by the 999 service . This must be recognised and factored in.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Single-sale availability of Emerade adrenaline auto injectors
Wider context from the report “4. The Emerade AAI is sold singly . It could be sold in boxes of two as the norm and only singly in the alternative.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 and emphasise the need to carry two adrenaline auto injector pens
Wider context from the report “2. Shanté’s GPs knew that she should carry two adrenaline auto injector (AAI) pens at all times, and they may have mentioned this to her, but they failed to record this and they did not emphasise it to her .
They failed to emphasise to Shanté and her family that the reason for carrying two pens is primarily because in the event of severe acute anaphylaxis, the very strong likelihood is that both pens will need to be administered, one five minutes after the other, to keep the patient alive until the arrival of an emergency ambulance.
The GPs did not explore with Shanté the reason for her erratic requests for a pen. They did not explore with her where she kept her pens. They did not test her understanding of medical advice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 prescribers to reconsider adrenaline auto injector dose after a device switch
Wider context from the report “8. The CCG failed to draw prescribers’ attention to the need, following scriptswitch from EpiPen to Emerade, to reconsider the dose and to prescribe the higher dose of 500mcgs for patients at higher risk (which would have included Shanté).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 display the advice to carry two adrenaline auto injectors on the outside of the box
Wider context from the report “3. The Emerade AAI accompanying leaflet does include the advice that two pens should be carried at all times, but the advice is not re-iterated on the outside of the box . Consideration will need to be given to whether this is the appropriate advice in all cases, but it seems worthwhile to review the issue as a whole.
” 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 Established NHS Pathways governance systems capture, review and resolve clinical coding issues, including those raised through Prevention of Future Deaths reports.
Verbatim wording from the response “In relation to NHS Pathways specifically, I am advised that there are established governance systems in place to capture, review and resolve issues relating to clinical coding (including from Prevention of Future Deaths reports); and to ensure latest clinical advice and guidance is reflected in call categorisation. Independent clinical scrutiny of NHS Pathways is provided by a National Clinical Governance Group that includes representatives of medical Royal Colleges.” Source location 2020-0124-Response-from-Department-of-Health-and-Social-Care_Redacted.pdf
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 NHSEI is responsible for clinical policy and strategy for allergies in the NHS in England, including specialised allergy services.
Verbatim wording from the response “20,000 (0.1 per cent) require referral to a specialist centre. These specialist services are commissioned at a national level by NHSEI to an agreed delivery specification.” Source location 2020-0124-Response-from-Department-of-Health-and-Social-Care_Redacted.pdf
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 Commissioning and management of general allergy services is a local responsibility rather than a national departmental responsibility.
Verbatim wording from the response “The commissioning and management of general allergy services is a local matter. For most patients (around 95 per cent) allergic diseases can be managed by primary or other non-specialist allergy services with routine therapy. Approximately five per cent of patients with allergies require treatment in a secondary service, and of those, around” Source location 2020-0124-Response-from-Department-of-Health-and-Social-Care_Redacted.pdf
Open published response
3 Jan 2020 James Thomas Wheeler · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to provide annual Care Act Reviews to eligible service users View source Lack of authoritative guidance on monitoring people with refractory epilepsy View source Insufficient resources for councils to undertake annual Care Act reviews View source Lack of guidance on the availability and use of assistive technology for monitoring people at high risk from seizures 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 Thomas Wheeler · 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 Thomas Wheeler, who had refractory epilepsy alongside cerebral palsy and severe learning disability, was found unresponsive at Cheddle Lodge on 22 January 2018 and died shortly afterwards. The inquest concluded that he died following a nocturnal epileptic seizure while unobserved and not actively monitored. Concerns included the lack of authoritative UK guidance on monitoring people with refractory epilepsy and assistive technology, failures to provide required annual Care Act Reviews, and insufficient resources for local authorities to fulfil those duties.
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 annual Care Act Reviews to eligible service users
Wider context from the report “2. To Ms Pam Smith, Chief Executive, Stockport Metropolitan Borough Council
The court heard evidence that, notwithstanding the Local Authority’s statutory obligations under the Care Act 2014 in this regard, Mr Wheeler (and indeed many other eligible service users) did not receive annual Care Act Reviews as required by law .
Whilst the court heard evidence about the process of transformation of adult social care underway within the Local Authority, it is a matter of concern that the default position still appears to be that an obligatory Care Act Review will not take place , unless some exceptional circumstance is identified about the case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 authoritative guidance on monitoring people with refractory epilepsy
Wider context from the report “1. To Sir Andrew Dillon, Chief Executive, National Institute of Health and Care Excellence
The court heard that there is currently an absence of authoritative guidance in the United Kingdom as to the monitoring of people with refractory epilepsy, both in hospital and community care settings .
A particular feature of this case was the absence of guidance as to the availability and use of assistive technology in monitoring individuals thought to be at high risk as a result of seizures.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 resources for councils to undertake annual Care Act reviews
Wider context from the report “3. To Rt. Hon. Matt Hancock, Secretary of State for Health and Social Care
The court heard evidence that, whilst parliament had conferred on Local Authorities a statutory duty to undertake annual reviews pursuant to the Care Act 2014, insufficient resources had been made available to enable councils to discharge this duty alongside existing statutory obligations .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 guidance on the availability and use of assistive technology for monitoring people at high risk from seizures
Wider context from the report “1. To Sir Andrew Dillon, Chief Executive, National Institute of Health and Care Excellence
The court heard that there is currently an absence of authoritative guidance in the United Kingdom as to the monitoring of people with refractory epilepsy, both in hospital and community care settings.
A particular feature of this case was the absence of guidance as to the availability and use of assistive technology in monitoring individuals thought to be at high risk as a result of seizures .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide councils with access to additional social care funding to support rising demand and stabilise services.
Verbatim wording from the response “To support local authorities, we are providing councils with access to an additional £1.5billion for adults and children’s social care next year. This includes an additional £1billion of grant funding for adults and children’s social care, and a proposed 2 per cent precept⁴ that will enable councils to access a further £500million for adult social care. This £1.5billion is on top of maintaining the £2.5billion of existing social care grants and will support local authorities to meet rising demand and continue to stabilise the social care system.” Source location 2020-0001-Response-from-the-Department-of-Health-and-Social-Care-Redacted-1
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 Stockport Council is responsible for meeting its statutory duty to conduct regular care-plan reviews.
Verbatim wording from the response “I am deeply concerned that the inquest into Mr Wheeler’s death found that annual reviews of his care were not conducted as required by the Social Care Act 2014¹. I am equally concerned at the suggestion in your report that Stockport Metropolitan Borough Council social services may not be carrying out annual reviews of care apart from under exceptional circumstances. I expect Stockport Council to look into this matter thoroughly.” Source location 2020-0001-Response-from-the-Department-of-Health-and-Social-Care-Redacted-1
Open published response
30 Dec 2019 Maureen Waterfall · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Lack of a national protocol for timely anticoagulant antidote administration View source Lack of a clear target time for anticoagulant antidote administration View source Lack of national standard guidance for storage of anticoagulant antidote supplies View source Failure to share anticoagulant reversal risks with non-tertiary centres View source Unavailability of anticoagulant antidote supplies at the resuscitation unit View source Absence of a currently licensed antidote for Edoxaban View source Limited ability to monitor the effectiveness of anticoagulant antidotes View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Maureen Waterfall · 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
Maureen Waterfall fell at home on 12 July 2019 while taking the anticoagulant Edoxaban and sustained a head injury that led to a subdural haematoma. She died at Willow Wood Hospice on 26 July 2019. Concerns included the lack of a licensed specific antidote for Edoxaban, uncertainty about treatment effectiveness and timing, the absence of national guidance, and the storage of antidote supplies away from the resuscitation unit.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a national protocol for timely anticoagulant antidote administration
Wider context from the report “2. The inquest was told that head injury patients who are prescribed Exodaban are at greater risk of continued bleeding to the brain than other patients as the absence of a specific antidote makes the reversal of the anticoagulant medication less certain. As with other newer anticoagulant drugs, there is little ability to monitor the effectiveness of the antidote. It was unclear if that understanding had been shared widely amongst non-tertiary centres to assist them in managing such patients.
The inquest was told that, at SRFT which is a tertiary centre for neuro surgery/ neurology they have taken steps to set a target for the use of anticoagulant antidote drugs at 90 minutes from presentation. It was unclear if this target was feeding into development of a national protocol . It was unclear how in the absence of national guidance that information was being shared with DGHs which rely on tertiary centres for expertise. At TGH there was no clear target time for the administration of anti-coagulations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear target time for anticoagulant antidote administration
Wider context from the report “2. The inquest was told that head injury patients who are prescribed Exodaban are at greater risk of continued bleeding to the brain than other patients as the absence of a specific antidote makes the reversal of the anticoagulant medication less certain. As with other newer anticoagulant drugs, there is little ability to monitor the effectiveness of the antidote. It was unclear if that understanding had been shared widely amongst non-tertiary centres to assist them in managing such patients.
The inquest was told that, at SRFT which is a tertiary centre for neuro surgery/ neurology they have taken steps to set a target for the use of anticoagulant antidote drugs at 90 minutes from presentation. It was unclear if this target was feeding into development of a national protocol. It was unclear how in the absence of national guidance that information was being shared with DGHs which rely on tertiary centres for expertise. At TGH there was no clear target time for the administration of anti-coagulations .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 standard guidance for storage of anticoagulant antidote supplies
Wider context from the report “3. I heard that there is no national standard guidance about the storage of supplies of anticoagulant antidote drugs . As a result, as in this case at Tameside General Hospital Accident and Emergency Department they were not kept at the resuscitation unit, but rather they were kept in the haematology 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 share anticoagulant reversal risks with non-tertiary centres
Wider context from the report “2. The inquest was told that head injury patients who are prescribed Exodaban are at greater risk of continued bleeding to the brain than other patients as the absence of a specific antidote makes the reversal of the anticoagulant medication less certain. As with other newer anticoagulant drugs, there is little ability to monitor the effectiveness of the antidote. It was unclear if that understanding had been shared widely amongst non-tertiary centres to assist them in managing such patients.
The inquest was told that, at SRFT which is a tertiary centre for neuro surgery/ neurology they have taken steps to set a target for the use of anticoagulant antidote drugs at 90 minutes from presentation. It was unclear if this target was feeding into development of a national protocol. It was unclear how in the absence of national guidance that information was being shared with DGHs which rely on tertiary centres for expertise. At TGH there was no clear target time for the administration of anti-coagulations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 anticoagulant antidote supplies at the resuscitation unit
Wider context from the report “3. I heard that there is no national standard guidance about the storage of supplies of anticoagulant antidote drugs. As a result, as in this case at Tameside General Hospital Accident and Emergency Department they were not kept at the resuscitation unit, but rather they were kept in the haematology 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 Absence of a currently licensed antidote for Edoxaban
Wider context from the report “1. I heard evidence from ████████ Clinical Director of Neurosciences at Salford Royal Hospital. He told me that Edoxaban was one of the new anticoagulant drugs, but of those with which he is familiar, it is differentiated by the fact that there is no currently licensed antidote . He is aware of clinical trials being undertaken of such an antidote.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Limited ability to monitor the effectiveness of anticoagulant antidotes
Wider context from the report “2. The inquest was told that head injury patients who are prescribed Exodaban are at greater risk of continued bleeding to the brain than other patients as the absence of a specific antidote makes the reversal of the anticoagulant medication less certain. As with other newer anticoagulant drugs, there is little ability to monitor the effectiveness of the antidote . It was unclear if that understanding had been shared widely amongst non-tertiary centres to assist them in managing such patients.
The inquest was told that, at SRFT which is a tertiary centre for neuro surgery/ neurology they have taken steps to set a target for the use of anticoagulant antidote drugs at 90 minutes from presentation. It was unclear if this target was feeding into development of a national protocol. It was unclear how in the absence of national guidance that information was being shared with DGHs which rely on tertiary centres for expertise. At TGH there was no clear target time for the administration of anti-coagulations.
” Open source report
24 Dec 2019 Julie Helen Taylor · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 11 Insufficient availability of acute learning disability beds View source Lack of a vaccination plan for people with Down Syndrome View source Failure to ensure effective psychiatrist and learning disability team communication in medication and care planning View source Incomplete digitisation preventing professionals from accessing each other's notes View source Failure to document decision-making rationales in inpatient notes View source Failure to recognise and put in place reasonable adjustment care plans in acute hospital departments View source Unavailability of appropriately trained wraparound support and care for people with learning disabilities in acute settings View source Failure to recognise chicken pox presentations in junior and dermatology clinicians View source Failure of interagency communication to produce a clear and effective care plan for people with learning disabilities View source Failure to hold formal best interests meetings for key inpatient decisions View source Failure of digital information access between acute and community trusts View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Julie Helen Taylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Julie Helen Taylor, who had Down syndrome and significant learning disabilities, died at Stepping Hill Hospital on 23 September 2018 from pneumonitis following a chicken pox virus infection contracted while awaiting discharge. The concerns included inadequate reasonable-adjustment planning, lack of best-interests meetings and documented decision-making, poor communication between agencies, limited access to suitable learning-disability beds and support, information-sharing difficulties, and delayed recognition of chicken pox.
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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 Insufficient availability of acute learning disability beds
Wider context from the report “4. The inquest also heard that a particular challenge existed where a need was identified for an acute learning disability bed. There was a very limited number of such beds available . In Derbyshire at the time of her need the unit had closed to new admissions and therefore any such bed would need to be sourced from outside the country from the limited number of national beds. The limited number of beds meant she may well have been placed many miles from her family and other familiar sights. The fact that one was not available in the county meant that she could not be moved straight away when the need was confirmed at a meeting in August 2018;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 vaccination plan for people with Down Syndrome
Wider context from the report “7. Julie Taylor was ultimately diagnosed with the chicken pox virus. The delayed diagnosis was due in part to the dermatology registrar not recognising the rash as chicken pox. The inquest heard that the reduction of chicken pox in the general population meant that junior doctors were less likely to recognise the rash and there could be a knock on delay in starting a person on anti-viral medications. This could be detrimental to their health and the eventual outcome as anti-virals were shown to have success in reducing fatalities in adults who contract the virus. There was no vaccination plan in place amongst the population with Down Syndrome although the inquest heard they were more likely statistically to develop it;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure effective psychiatrist and learning disability team communication in medication and care planning
Wider context from the report “5. Prior to her significant deterioration in the community the inquest heard that there was some communication between her community psychiatrist and the learning disability team. There was limited evidence of a joint approach between the psychiatrist and learning disability team where the prescriber in that team changed the medication . Her consultant was not present at the key meetings at the end of July/August and therefore a clear clinical steer from the psychiatrist was not available to the meetings . It was unclear what expectations there should be nationally around attendance and where a key member of the team could not attend how to ensure effective communication of their views before and after meetings ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Incomplete digitisation preventing professionals from accessing each other's notes
Wider context from the report “8. The IT constraints meant that the acute trust could not access the community trusts records. The community trust itself had not fully digitised meaning not all professionals could see each other's notes . The community trust recognised the internal issue and was taking steps to fully roll out an integrated system however communication between trusts digitally was unlikely to improve despite a recognition that it would be beneficial.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to document decision-making rationales in inpatient notes
Wider context from the report “2. No formal best interests meeting(s) was/were held whilst Julie Taylor was an inpatient at the acute hospital. Key decisions were taken regarding what tests to carry out; whether to nurse her and whether to place her on End of Life care without the benefit of a best interests meeting. Decisions were taken with no rationale for them being documented in her notes . The inquest heard that the trust had taken steps to promote the use of best interests meetings/improved documentation in similar cases in the future but that nationally there was a lack of consistency around the use of best interests meetings/documentation of decision making and rationales for those decisions ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 and put in place reasonable adjustment care plans in acute hospital departments
Wider context from the report “1. The inquest heard that upon her admission to hospital the Emergency Department, where she spent a prolonged period of time, and Acute Medical Unit (AMU), had not recognised the need for a reasonable adjustment care plan to help them understand her complex needs. One was not put in place until she reached a medical ward . The trust had taken steps to rectify the position and avoid it happening again. The inquest heard that it was unclear if nationally there was a clear understanding in Emergency Departments and AMU's of the need for reasonable care adjustment plans and the impact that lack of provision could have on delivering effective care to those with learning disabilities in an acute setting;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 appropriately trained wraparound support and care for people with learning disabilities in acute settings
Wider context from the report “6. In her community care setting Julie Taylor had wraparound care provided by carers who knew her well and were trained to deal with someone with her profound needs. In the acute setting that level of support and care was not available . As a result she became distressed and increasingly less compliant with necessary medical interventions. The inquest heard that the issue of support that can be provided to those with a learning disability in an acute setting is not particular to the trust involved in Julie's death but a national one;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 chicken pox presentations in junior and dermatology clinicians
Wider context from the report “7. Julie Taylor was ultimately diagnosed with the chicken pox virus. The delayed diagnosis was due in part to the dermatology registrar not recognising the rash as chicken pox . The inquest heard that the reduction of chicken pox in the general population meant that junior doctors were less likely to recognise the rash and there could be a knock on delay in starting a person on anti-viral medications. This could be detrimental to their health and the eventual outcome as anti-virals were shown to have success in reducing fatalities in adults who contract the virus. There was no vaccination plan in place amongst the population with Down Syndrome although the inquest heard they were more likely statistically to develop it;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of interagency communication to produce a clear and effective care plan for people with learning disabilities
Wider context from the report “3. Prior to her admission to the acute hospital there had been on-going discussion about her deteriorating condition and where her care needs could more effectively be met. The inquest heard that both in the community and subsequently in the acute setting there was a need for improved communication between agencies /professionals to ensure a clear, consistent and effective plan was put in to meet the needs of those with a learning disability . In her case it was recognised at the end of July that a learning disability acute bed would be beneficial. Driving that forward was limited by a number of factors including communication between agencies involved ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 hold formal best interests meetings for key inpatient decisions
Wider context from the report “2. No formal best interests meeting(s) was/were held whilst Julie Taylor was an inpatient at the acute hospital. Key decisions were taken regarding what tests to carry out; whether to nurse her and whether to place her on End of Life care without the benefit of a best interests meeting . Decisions were taken with no rationale for them being documented in her notes. The inquest heard that the trust had taken steps to promote the use of best interests meetings/improved documentation in similar cases in the future but that nationally there was a lack of consistency around the use of best interests meetings/documentation of decision making and rationales for those decisions;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 digital information access between acute and community trusts
Wider context from the report “8. The IT constraints meant that the acute trust could not access the community trusts records . The community trust itself had not fully digitised meaning not all professionals could see each other's notes. The community trust recognised the internal issue and was taking steps to fully roll out an integrated system however communication between trusts digitally was unlikely to improve despite a recognition that it would be beneficial .
” 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 Introduce mandatory learning disability and autism training for health and care staff.
Verbatim wording from the response “disabilities. For this reason, we consulted on the introduction of mandatory learning disability and autism training for health and care staff.” Source location 2019-0454-Response-from-the-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 Publish an evidence review of care co-ordination for people with learning disabilities, focused on health and wellbeing.
Verbatim wording from the response “Both the second⁴ and the third⁵ annual LeDeR reports highlighted the importance of care co-ordination. We committed to publishing an evidence review of care co-ordination for people with learning disability, focused on health and wellbeing. Once this work is complete, we will be better placed to understand how this can be used to inform how care co-ordination is delivered across the health and social care sector for people with a learning disability, particularly in relation to developing guidance.” Source location 2019-0454-Response-from-the-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 Develop and test a standardised learning disability and autism training package with Health Education England and Skills for Care.
Verbatim wording from the response “disabilities. For this reason, we consulted on the introduction of mandatory learning disability and autism training for health and care staff.” Source location 2019-0454-Response-from-the-Department-of-Health-and-Social-Care
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current evidence does not establish increased susceptibility or poorer varicella outcomes in children with Down’s syndrome; further research is required.
Verbatim wording from the response “In response to another Prevention of Future Deaths Report, the Varicella Zoster subcommittee of the Joint Committee on Vaccination and Immunisation (JCVI) has previously considered whether there is an increased risk of serious varicella infection in children with Downs syndrome. In his response to the Coroner, dated 22 August 2019, Prof Andy Pollard, Chair of the JCVI, said:” Source location 2019-0454-Response-from-the-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 A formal best-interests meeting is not a statutory duty, although decision-makers must comply with the Mental Capacity Act consultation requirements.
Verbatim wording from the response “Your report explains that a best interests meeting was not held while Ms Taylor was an inpatient at Stepping Hill Hospital. While a formal best interests meeting is not a duty, under section 4 of the Mental Capacity Act (2005)⁶ (MCA), the decision maker must take into account, if it is practicable and appropriate to consult them, the views of anyone named by the person as someone to be consulted; anyone engaged in caring for the person or interested in their welfare; and any person with lasting power of attorney or a deputy appointed by a court.” Source location 2019-0454-Response-from-the-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 local NHS is expected to reflect on the LeDeR findings and address local failings in care for people with learning disabilities.
Verbatim wording from the response “I am advised by NHS England and NHS Improvement that Ms Taylor’s death is currently being reviewed under the LeDeR process and I expect the local NHS to reflect on the findings of the review and take action to address any failings in the care provided locally for people with a learning disability. I have also asked officials to bring your report to the attention of the National Director for Learning Disabilities, Ray James, who is leading work nationally to improve services for people with learning disabilities and/or autism.” Source location 2019-0454-Response-from-the-Department-of-Health-and-Social-Care
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations