17 Dec 2019 Lewis Victor Mendelson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 10 Failure to provide an IMCA during hospital treatment View source Failure to hold a formal best interests meeting during hospital treatment View source Failure of treating physicians to understand the complexity of learning disability and communication issues View source Failure to put required DoLS authorisations in place View source Repeated distressing nasogastric tube insertion attempts with limited evidence of benefit View source Failure to discuss End of Life Care with an IMCA View source Failure to assess the appropriate care if the patient rallied during End of Life Care View source Delays in required annual care reviews View source Failure to hold a best interests meeting for End of Life Care View source Absence of a designated social worker overseeing care View source See 7 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
Lewis Victor Mendelson · 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
Lewis Victor Mendelson, who had profound learning and physical disabilities, became unwell after vomiting on 8 May 2019, was taken to hospital, later received end-of-life care, and died at home on 16 May 2019. The concerns included the absence of a DoLS authorisation, statutory care review and allocated social worker, as well as hospital treatment and end-of-life decisions without a formal best interests meeting or IMCA involvement.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an IMCA during hospital treatment
Wider context from the report “2. He was treated in hospital with no IMCA in place or formal best interests meeting taking place. As a result it was unclear if the treating physicians understood the complexity of his learning disability and communication issues that flowed from his disability. The inquest heard that repeated attempts were made to insert a nasogastric tube causing him great distress and where there was limited evidence 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 hold a formal best interests meeting during hospital treatment
Wider context from the report “2. He was treated in hospital with no IMCA in place or formal best interests meeting taking place. As a result it was unclear if the treating physicians understood the complexity of his learning disability and communication issues that flowed from his disability. The inquest heard that repeated attempts were made to insert a nasogastric tube causing him great distress and where there was limited evidence 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 of treating physicians to understand the complexity of learning disability and communication issues
Wider context from the report “2. He was treated in hospital with no IMCA in place or formal best interests meeting taking place. As a result it was unclear if the treating physicians understood the complexity of his learning disability and communication issues that flowed from his disability . The inquest heard that repeated attempts were made to insert a nasogastric tube causing him great distress and where there was limited evidence 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 put required DoLS authorisations in place
Wider context from the report “1. The inquest was told that he met the criteria for a DoLS but due to backlogs within the Local Authority one was not in place at the time of his death . He also met the criteria for an annual review of his care - this had not taken place for over 2 years due to staff shortages. There was no designated Social worker overseeing his care due to staffing shortages;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Repeated distressing nasogastric tube insertion attempts with limited evidence of benefit
Wider context from the report “2. He was treated in hospital with no IMCA in place or formal best interests meeting taking place. As a result it was unclear if the treating physicians understood the complexity of his learning disability and communication issues that flowed from his disability. The inquest heard that repeated attempts were made to insert a nasogastric tube causing him great distress and where there was limited evidence 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 discuss End of Life Care with an IMCA
Wider context from the report “3. He was placed on End of Life Care with no best interests meeting taking place or discussion with an IMCA or assessment of what should happen if he rallied – as he did.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 the appropriate care if the patient rallied during End of Life Care
Wider context from the report “3. He was placed on End of Life Care with no best interests meeting taking place or discussion with an IMCA or assessment of what should happen if he rallied – as he did.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 required annual care reviews
Wider context from the report “1. The inquest was told that he met the criteria for a DoLS but due to backlogs within the Local Authority one was not in place at the time of his death. He also met the criteria for an annual review of his care - this had not taken place for over 2 years due to staff shortages . There was no designated Social worker overseeing his care due to staffing shortages;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 a best interests meeting for End of Life Care
Wider context from the report “3. He was placed on End of Life Care with no best interests meeting taking place or discussion with an IMCA or assessment of what should happen if he rallied – as he did.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 designated social worker overseeing care
Wider context from the report “1. The inquest was told that he met the criteria for a DoLS but due to backlogs within the Local Authority one was not in place at the time of his death. He also met the criteria for an annual review of his care - this had not taken place for over 2 years due to staff shortages. There was no designated Social worker overseeing his care due to staffing shortages;
” Open source report
16 Dec 2019 Joyce Marchant · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to provide GPs with timely and reliable blood-results and follow-up information View source Shortage of interventional radiologists delaying access to drainage procedures View source Lack of a clear communication strategy and treatment plan between DGHs and tertiary centres View source Delays and impracticability in transferring patients to tertiary centres for drainage procedures View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Joyce Marchant · 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
Joyce Marchant died at Tameside General Hospital on 1 June 2019 from complications of a liver abscess, including biliary sepsis and multi-organ failure. The report identified concerns about delays in arranging drainage because of limited interventional radiology capacity, delayed communication of abnormal results to her GP through the postal system, and the lack of a clear communication strategy between the district general hospital and tertiary centre.
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 GPs with timely and reliable blood-results and follow-up information
Wider context from the report “2. The inquest heard that the Manchester Royal Infirmary use the postal system to provide GPs with information about blood results/follow up information . Faxes are no longer used due to GDPR. The trust propose to move to an email system for notifying GPs recognising that the use of the postal system carries delay and risk of information not reaching the GP(7% was the figure given to the inquest) . Their IT system at this time is not capable of this information transfer and the information was that it would be about another 2-3 years before that was achieved. In the interim they would continue to use the postal 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 Shortage of interventional radiologists delaying access to drainage procedures
Wider context from the report “1. During the course of the Inquest the evidence given was that the delay in offering the drainage procedure was attributable to a shortage of interventional radiologists which meant that the Trust could not accommodate the need for a drainage procedure until 31st May . There was greater availability at tertiary centres but transfers to tertiary centre could take time and not be practicable. The inquest heard that if she had been at the tertiary centre when the abscess was identified she would probably have had the drainage procedure almost straight away;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 communication strategy and treatment plan between DGHs and tertiary centres
Wider context from the report “3. The MRI was the treating centre for Mrs Marchant’s underlying medical problems which led to her deterioration. However there was no evidence of a clear communication strategy or treatment plan involving the DGH and Tertiary Centre . This was attributed in part to the sheer volume of demand on tertiary centres and the extent of support they can provide to DGHs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 and impracticability in transferring patients to tertiary centres for drainage procedures
Wider context from the report “1. During the course of the Inquest the evidence given was that the delay in offering the drainage procedure was attributable to a shortage of interventional radiologists which meant that the Trust could not accommodate the need for a drainage procedure until 31st May. There was greater availability at tertiary centres but transfers to tertiary centre could take time and not be practicable . The inquest heard that if she had been at the tertiary centre when the abscess was identified she would probably have had the drainage procedure almost straight away;
” Open source report
13 Dec 2019 Steven Keith Marsland · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Failure to engage families and work with them to support people in the community View source Lack of a clear CMHT policy for effectively engaging families View source Failure to provide regular CMHT contact in the community View source Failure to escalate or discuss very limited post-discharge contact View source Failure to make a follow-up appointment at discharge View source Failure to allocate people moving between borough teams to a community psychiatrist View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Steven Keith Marsland · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Steven Keith Marsland, who had a complex mental health background, was found suspended from a ligature on 10 June 2019; the inquest conclusion was suicide and the medical cause of death was hanging. Concerns included insufficient engagement with his family after discharge, failure to arrange a community psychiatric follow-up appointment, and limited contact with the Community Mental Health Team without escalation or discussion.
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 engage families and work with them to support people in the community
Wider context from the report “1. The inquest heard that his family were very supportive and had attended MDT meetings whilst he was an in-patient. Following his discharge there was no attempt to engage his family and obtain information from them or work with them to support him in the community. There was no clear policy about how a family could be effectively engaged by the CMHT;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 CMHT policy for effectively engaging families
Wider context from the report “1. The inquest heard that his family were very supportive and had attended MDT meetings whilst he was an in-patient. Following his discharge there was no attempt to engage his family and obtain information from them or work with them to support him in the community. There was no clear policy about how a family could be effectively engaged by the CMHT ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 regular CMHT contact in the community
Wider context from the report “3. The inquest heard that it was recognised as part of his discharge planning that there should be regular contact in the community with the CMHT. That did not happen and there was no escalation or discussion about the picture of very limited contact as it evolved post discharge.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 or discuss very limited post-discharge contact
Wider context from the report “3. The inquest heard that it was recognised as part of his discharge planning that there should be regular contact in the community with the CMHT. That did not happen and there was no escalation or discussion about the picture of very limited contact as it evolved post discharge .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 a follow-up appointment at discharge
Wider context from the report “2. The inquest heard that he was treated as an in-patient by the Pennine Care team within Stockport MBC. His consultant whilst he was an in-patient was part of the Stockport Team. If he had been a Stockport Resident he would have been discharged under the care of that consultant in the community and had a follow up appointment booked with that Doctor at discharge. However because he was a Tameside Resident at discharge his care moved to the Tameside Borough Pennine Care Team. That meant he had to be allocated to a community psychiatrist based there. That did not happen and no follow up appointment was made ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate people moving between borough teams to a community psychiatrist
Wider context from the report “2. The inquest heard that he was treated as an in-patient by the Pennine Care team within Stockport MBC. His consultant whilst he was an in-patient was part of the Stockport Team. If he had been a Stockport Resident he would have been discharged under the care of that consultant in the community and had a follow up appointment booked with that Doctor at discharge. However because he was a Tameside Resident at discharge his care moved to the Tameside Borough Pennine Care Team. That meant he had to be allocated to a community psychiatrist based there. That did not happen and no follow up appointment was made;
” Open source report
29 Nov 2019 LEAH LOUISE CAMBRIDGE · Prevention of Future Deaths report West Yorkshire (East)
View report summary
Concerns raised 3 Lack of prescribed regulatory guidance on BBL surgical techniques View source Lack of regulatory intervention and control of BBL procedures in the UK View source Failure to obtain informed consent for BBL procedures 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
LEAH LOUISE CAMBRIDGE · 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
Leah Louise Cambridge, aged 29, travelled to Izmir, Turkey, for a Brazilian Butt Lift under general anaesthetic and died during the procedure on 27 August 2018. A post-mortem examination found that fat had entered veins in her body, causing a fat embolism. The concerns included continued UK involvement in BBL procedures, inadequate informed consent, and a lack of regulatory intervention and control.
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 prescribed regulatory guidance on BBL surgical techniques
Wider context from the report “(3) If BBL procedures continue to be permitted in the UK, I consider there is a need for the regulatory authorities to consider prescribing guidance on the surgical techniques to be employed and the information to be provided before a person incurs expense.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory intervention and control of BBL procedures in the UK
Wider context from the report “(1) Notwithstanding
(a) the death of Ms Cambridge on 27.8.18; and
(b) concerns expressed in relation to the risks involved in BBL procedures by a task force established under the auspices of the Aesthetic Surgery Education and Research Foundation (ASERF); and
(c) a voluntary moratorium declared by the British Association of Aesthetic and Plastic Surgeons (‘BAAPS’)
The Inquest heard evidence that some plastic surgeons in the UK continue to carry out BBL procedures. Furthermore, that Elite Aftercare continue to facilitate other clients to travel to Turkey for the purpose of BBL procedures to be undertaken by surgeons such as ████████.
I am concerned at the lack of intervention and control of BBL procedures by the regulatory authorities in the UK.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain informed consent for BBL procedures
Wider context from the report “(2) In order to make an informed decision as to the wisdom of undertaking effective cosmetic surgical procedures such as BBL, it is important that the person involved receive adequate information regarding the mortality and morbidity risks involved . In order to read and absorb such information it needs to be provided prior to any commitment being made or expense incurred . The Inquest into the death of Ms Cambridge heard that she was provided with a substantial quantity of material (some of which was written in Turkish) on the morning of the surgery and required to sign each page. The Inquest found she had insufficient time to digest this complex material, even if she was in a frame of mind to try, shortly before being taken to theatre. My concern is that informed consent is not obtained.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update existing surgical fat transfer guidance to reference Brazilian Butt Lift procedures, informed by stakeholder liaison and current clinical information.
Verbatim wording from the response “The Department will be updating existing guidance about surgical fat transfer procedures, which the Brazilian ButtLift falls under, to reference the procedure. The Department is liaising with stakeholders to check the latest clinical information and expects the updates to guidance to be made by March 2020.” Source location 2019-0408-Response-from-The-Department-of-Health-and-Social-Care
Open published response
22 Nov 2019 MAUREEN MILTON · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 2 Lack of awareness of petrol-based emollient fire risks View source Fire ignition of clothing impregnated with petrol-based emollient cream 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
MAUREEN MILTON · 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 Milton, aged 74, died after her clothing caught fire while she was attempting to light a cigarette with a long match; petrol-based emollient cream on her clothing likely accelerated the fire, and she was pronounced dead at the scene. The principal concern was a lack of awareness among medical professionals, carers, victims and families about the fire risks associated with petrol-based emollients.
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 awareness of petrol-based emollient fire risks
Wider context from the report “Evidence given by fire investigators was that they are increasingly attending fires involving (mostly) the elderly where there is evidence of petrol based emollient cream in use. The petrol base is found in a significant number of prescribed creams and creams (such as moisturisers) which are readily available over the counter. This cream impregnates clothing and is not washed away during a normal washing programme. In the event of a fire the victim is rapidly engulfed by flames with little chance of survival. The cause of death is generally burns, not inhalation of smoke. The concern is the lack of awareness of this problem by medical professionals, carers, victims and their families. It is felt appropriate heighten awareness of this growing problem amongst health professionals and others who work in the field of prescribing such creams and those caring for patients using petrol based emollients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Fire ignition of clothing impregnated with petrol-based emollient cream
Wider context from the report “Evidence given by fire investigators was that they are increasingly attending fires involving (mostly) the elderly where there is evidence of petrol based emollient cream in use. The petrol base is found in a significant number of prescribed creams and creams (such as moisturisers) which are readily available over the counter. This cream impregnates clothing and is not washed away during a normal washing programme. In the event of a fire the victim is rapidly engulfed by flames with little chance of survival. The cause of death is generally burns, not inhalation of smoke. The concern is the lack of awareness of this problem by medical professionals, carers, victims and their families. It is felt appropriate heighten awareness of this growing problem amongst health professionals and others who work in the field of prescribing such creams and those caring for patients using petrol based emollients.
” 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 Launch the emollient-risk toolkit with a press release and coordinated dissemination of key messages through stakeholder networks.
Verbatim wording from the response “I am advised that the group has met twice, most recently on 10 December 2019, and is working towards producing a toolkit of resources for patients, their carers’, healthcare professionals, health organisations and healthcare professional educators. The Government welcomes plans by the MHRA to officially launch the toolkit in 2020. This will be accompanied by a MHRA press release and stakeholders will propagate the key messages through their networks at the same time.” Source location 2019-0396-Response-by-Department-of-Health-and-Social-Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate information about severe and fatal burns associated with paraffin-containing and paraffin-free emollients through safety communications.
Verbatim wording from the response “The MHRA advises that it most recently communicated information about the risk of severe and fatal burns with paraffin-containing and paraffin-free emollients in December 2018 through a press release and an article in Drug Safety Update¹. These communications resulted from an in-depth review of this issue by the MHRA’s independent expert advisory committee, the Commission on Human Medicines (CHM).” Source location 2019-0396-Response-by-Department-of-Health-and-Social-Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Design and optimise sustainable training and educational resources and their distribution and access to maintain awareness of emollient fire risks.
Verbatim wording from the response “bodies, organisations that provide guidance to health and social care workers, patient representatives and organisations that speak for relevant patient populations such as the National Eczema Society. The stakeholder group is designing and optimising sustainable training and educational resources for healthcare professionals and the public and their method of distribution and access, to ensure these are impactful and maintain long-term awareness of the risk of emollient creams.” Source location 2019-0396-Response-by-Department-of-Health-and-Social-Care
Open published response
19 Nov 2019 Katie Croft · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 15 Failure to share Child and Family Assessments in accordance with best practice View source Unclear dissemination of safeguarding investigation lessons beyond the local area View source Failure to establish available recordings and the scope of relevant social media evidence before case closure View source Lack of a formal school follow-up procedure after a Child and Family Assessment View source Lack of a mechanism for schools to receive relevant Child and Family Assessment information View source Failure to conduct a further face-to-face conversation with the child View source Lack of clear exam-board guidance for teachers to minimise risk to pupils when teaching sensitive material View source Failure to consider victimless prosecution before closing matters View source Failure to provide teachers with relevant information about a pupil's self-harm history and vulnerability View source Failure to fully hear the voice of the child throughout safeguarding investigations View source Failure to ensure case officers attend safeguarding strategy meetings View source Failure to complete Child and Family Assessments in accordance with best practice amid reliance on agency social workers View source Lack of officer capability in joint working with social services and applying the voice of the child View source Delays in seizing key digital evidence View source Failure to allocate appropriately experienced specialist officers to alleged sexual offences View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Katie Croft · 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
Katie Croft was a vulnerable child who had reported abuse and later disclosed thoughts of self-harm. She was found suspended from a ligature at home, sustained catastrophic brain damage, and died in hospital on 15 January 2019. Concerns included shortcomings in the police and social-care responses, failures to fully hear Katie’s voice and share relevant information, and uncertainty about guidance for schools teaching material involving suicide to vulnerable pupils.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to share Child and Family Assessments in accordance with best practice
Wider context from the report “2. The Local Authority at the time were using a substantial number of agency social workers. As a result the Child and Family Assessment was not completed in accordance with best practice and not shared in accordance with expectations around best practice . The Local Authority has since made significant progress in moving away from a reliance on agency staff to fill gaps in social work cover. The inquest was told that agency social workers are still used extensively in other Local Authorities creating a risk that a similar situation could arise;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 dissemination of safeguarding investigation lessons beyond the local area
Wider context from the report “4. It was accepted by witnesses for both the Local Authority and GMP that the voice of the child was not fully heard throughout their investigations. They via the safeguarding board commissioned an independent report whose findings and recommendations have been fully adopted by the safeguarding board. It was unclear what if any steps would be taken to disseminate the lessons pan GM or nationally ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to establish available recordings and the scope of relevant social media evidence before case closure
Wider context from the report “1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer. It was allocated to a probationary police constable with approximately 6 months experience. The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed. The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case. At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages . No attempt was made to have a further face to face conversation with Katie;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 formal school follow-up procedure after a Child and Family Assessment
Wider context from the report “5. A further concern identified was that there was no mechanism for the school to be formally aware of information within the Child and Family Assessment. As a result there was no formal follow-up procedure set out in the best practice national guidance the school was working within . The inquest heard that Katie’s school recognising this gap has built on the working together guidance to develop guidance that ensures there is a proactive approach to engaging with a child and their family post the writing of a Child and Family Assessment;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for schools to receive relevant Child and Family Assessment information
Wider context from the report “5. A further concern identified was that there was no mechanism for the school to be formally aware of information within the Child and Family Assessment . As a result there was no formal follow-up procedure set out in the best practice national guidance the school was working within. The inquest heard that Katie’s school recognising this gap has built on the working together guidance to develop guidance that ensures there is a proactive approach to engaging with a child and their family post the writing of a Child and Family Assessment;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a further face-to-face conversation with the child
Wider context from the report “1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer. It was allocated to a probationary police constable with approximately 6 months experience. The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed. The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case. At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages. No attempt was made to have a further face to face conversation with Katie ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 exam-board guidance for teachers to minimise risk to pupils when teaching sensitive material
Wider context from the report “6. On the day Katie committed suicide she had attended a GCSE English class. The exam board required poetry syllabus was being studied that day. The lesson included a poem where the contextualisation of it included the use of suicide. The teacher delivering the lesson had no way of understanding the history of self-harm of Katie and her particular vulnerability when delivering a set text in accordance with the exam board requirements. It was unclear what if any guidance is given by the exam board to assist teachers minimising risk to pupils in this scenario .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to consider victimless prosecution before closing matters
Wider context from the report “1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer. It was allocated to a probationary police constable with approximately 6 months experience. The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed. The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case. At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution ; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages. No attempt was made to have a further face to face conversation with Katie;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 teachers with relevant information about a pupil's self-harm history and vulnerability
Wider context from the report “6. On the day Katie committed suicide she had attended a GCSE English class. The exam board required poetry syllabus was being studied that day. The lesson included a poem where the contextualisation of it included the use of suicide. The teacher delivering the lesson had no way of understanding the history of self-harm of Katie and her particular vulnerability when delivering a set text in accordance with the exam board requirements. It was unclear what if any guidance is given by the exam board to assist teachers minimising risk to pupils in this scenario.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 fully hear the voice of the child throughout safeguarding investigations
Wider context from the report “4. It was accepted by witnesses for both the Local Authority and GMP that the voice of the child was not fully heard throughout their investigations . They via the safeguarding board commissioned an independent report whose findings and recommendations have been fully adopted by the safeguarding board. It was unclear what if any steps would be taken to disseminate the lessons pan GM or nationally;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure case officers attend safeguarding strategy meetings
Wider context from the report “3. At the safeguarding strategy meeting an officer allocated to attend such meetings on behalf of GMP attended rather than an officer allocated to the case . As a result the quality of information sharing and understanding of the allegation was more limited . On the particular police division in question this practice has stopped. It was unclear how common the approach is on a wider basis;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to complete Child and Family Assessments in accordance with best practice amid reliance on agency social workers
Wider context from the report “2. The Local Authority at the time were using a substantial number of agency social workers . As a result the Child and Family Assessment was not completed in accordance with best practice and not shared in accordance with expectations around best practice. The Local Authority has since made significant progress in moving away from a reliance on agency staff to fill gaps in social work cover. The inquest was told that agency social workers are still used extensively in other Local Authorities creating a risk that a similar situation could arise;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 officer capability in joint working with social services and applying the voice of the child
Wider context from the report “1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer. It was allocated to a probationary police constable with approximately 6 months experience. The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed. The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case . At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages. No attempt was made to have a further face to face conversation with Katie;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 seizing key digital evidence
Wider context from the report “1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer. It was allocated to a probationary police constable with approximately 6 months experience. The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed . The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case. At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages. No attempt was made to have a further face to face conversation with Katie;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 allocate appropriately experienced specialist officers to alleged sexual offences
Wider context from the report “1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer . It was allocated to a probationary police constable with approximately 6 months experience . The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed. The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case. At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages. No attempt was made to have a further face to face conversation with Katie;
” Open source report
18 Nov 2019 Deborah Michelle HEADSPEATH · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 4 Lack of mandatory online-prescription guidance and effective sanctions for non-adherence View source Failure to regulate online suppliers of prescription-only medication View source Lack of a comprehensive database of patients’ prescription-only medication View source Failure to prevent uncoordinated quantities of prescription-only medication from online suppliers 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
Deborah Michelle HEADSPEATH · 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
Debbie Headspeath died suddenly at home on 28 July 2017 from aspiration pneumonitis caused by pancreatitis, which was linked in the report to long-term codeine use. The principal concerns were the lack of a central database for prescription-only medicines, uncoordinated access to codeine from multiple online suppliers, and the ability of some suppliers to operate outside the CQC regulatory regime.
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 mandatory online-prescription guidance and effective sanctions for non-adherence
Wider context from the report “3. New guidance from the General Pharmaceutical Council was issued in April 2019 and this includes specific advice regarding on-line prescriptions. This is clearly welcome, however some witnesses highlighted that the guidance is advisory and not mandatory. As such there was some uncertainty as to what sanctions would be available against any supplying pharmacist who chose not to adhere to the new guidance?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 regulate online suppliers of prescription-only medication
Wider context from the report “2. Evidence was heard from both the CQC and CQC registered on-line pharmacists of the changes that have been made to the way in which the prescription of opiate based medication (including codeine) is now conducted. CQC registered pharmacies should now not supply opiate based medications unless the patient provides permission for them to contact their registered GP. However, those suppliers who do not want to adhere to this requirement are simply changing their business model (primarily by only using prescribing doctors based overseas) and are relinquishing their CQC Regulated status. These prescribers are therefore still able to provide on-line prescription services (including opiate based medication) in the UK but now fall outside the CQC regulation regime. Clearly this is an area of concern as it will continue to allow patients to access uncoordinated quantities of prescription only medication from unregulated on-line suppliers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 comprehensive database of patients’ prescription-only medication
Wider context from the report “1. There is no single database that allows a prescribing clinician to identify what prescription only medication has already been prescribed to any particular patient. Because there is no central record, in order for the prescribing clinician to identify previous/current prescriptions, they need to personally contact every other prescribing clinician or clinicians. Before being able to do this they would need to obtain the patients express permission. The evidence heard clearly demonstrated that this system was totally ineffective in Debbie’s case, especially so in relation to the supplies of prescription only medication from on-line.
It was identified that in relation to the prescription of opiate based drugs on-line that the NHS Business Authority already collates that data for NHS prescribers. However, this information is currently used for statistical purposes only and does not include any prescriptions from third party providers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 uncoordinated quantities of prescription-only medication from online suppliers
Wider context from the report “2. Evidence was heard from both the CQC and CQC registered on-line pharmacists of the changes that have been made to the way in which the prescription of opiate based medication (including codeine) is now conducted. CQC registered pharmacies should now not supply opiate based medications unless the patient provides permission for them to contact their registered GP. However, those suppliers who do not want to adhere to this requirement are simply changing their business model (primarily by only using prescribing doctors based overseas) and are relinquishing their CQC Regulated status. These prescribers are therefore still able to provide on-line prescription services (including opiate based medication) in the UK but now fall outside the CQC regulation regime. Clearly this is an area of concern as it will continue to allow patients to access uncoordinated quantities of prescription only medication from unregulated on-line suppliers.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with regulators to identify options for addressing online providers’ attempts to circumvent regulatory scrutiny.
Verbatim wording from the response “In relation to your concern that online providers are changing their business model to circumvent regulatory scrutiny, the Department is working with the CQC and other regulators to understand what the options might be to address this.” Source location 2019-0387-Response-from-The-Department-of-Health-and-Social-Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with regulators to improve oversight of online prescribers and address legislative regulatory gaps.
Verbatim wording from the response “The Department is working closely with the Care Quality Commission (CQC) and relevant professional regulators to look at how they can better regulate online prescribers and close the loopholes in legislation that allow a small number of online organisations to operate without the necessary oversight.” Source location 2019-0387-Response-from-The-Department-of-Health-and-Social-Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Oversight of online providers outside CQC regulation may fall to the General Pharmaceutical Council or Medicines and Healthcare products Regulatory Agency.
Verbatim wording from the response “Where a provider is outside the scope of CQC regulation, oversight might fall to other regulators, namely the GPhC and the Medicines and Healthcare products Regulatory Agency (MHRA), and I am assured that all three regulators are working collaboratively to share information where there are concerns about a provider.” Source location 2019-0387-Response-from-The-Department-of-Health-and-Social-Care
Open published response
15 Nov 2019 Averil Skoric · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of clear guidance on safe sleeping positioning of vulnerable adults in care homes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Averil Skoric · 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
Averil Skoric, who had vascular dementia, frailty and very limited mobility, was placed in bed on her back in a care home on 3 March 2018 and found on her front the following day. The report states that she died from positional asphyxia after moving into an unsafe sleeping position. The concern was that there was no clear local or national guidance for safely positioning vulnerable adults during sleep and overnight care.
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 clear guidance on safe sleeping positioning of vulnerable adults in care homes
Wider context from the report “The inquest was told that:
Mrs Skoric was a vulnerable resident who lacked capacity. Once she was on her front she was unable to move herself back into a safe sleeping position.
She had to be regularly moved during the course of a night to check to see if she needed changing. There was no clear guidance available to care home staff locally or nationally about safe sleeping positioning of vulnerable adults in their care to avoid this cadre of adults being placed in a position which created an increased risk of unsafe sleeping.
” 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 regulations and the CQC assessment framework are sufficiently broad to address safe care across providers and residents’ needs.
Verbatim wording from the response “Although there is no specific guidance concerning safe sleeping positions of residents who lack capacity or are at risk from the consequences of unsafe sleeping, the CQC expects a provider, caring for someone with the type of needs that Mrs Skoric had, to meet the fundamental standards as outlined in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.¹ This includes:” Source location 2019-0383-Response-from-The-Department-of-Health-and-Social-Care-Redacted
Open published response
14 Nov 2019 Joanna Clare Alice Flynn · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2 Inadequate training and education for general practitioners and GP practices in care for patients dependent on prescribed opiates View source Lack of specialised assistance and referral agencies for general practitioners supporting patients dependent on prescribed opiates View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joanna Clare Alice Flynn · 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
Joanna Clare Alice Flynn, aged 31, was found slumped over her bed on 26 May 2019 after last being seen on 23 May 2019. The inquest returned an Open conclusion against a background of long-standing prescribed opiate addiction, with concerns about the lack of specialised support and referral pathways for patients needing help to withdraw from addictive prescription drugs, as well as GP training and education.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate training and education for general practitioners and GP practices in care for patients dependent on prescribed opiates
Wider context from the report “The General Practitioner who gave evidence told the court that there was a lacuna in the healthcare provided for patients such as the deceased in terms of giving assistance for weaning off addictive prescription drugs such as opiates. It was clear that General Practitioner’s require highly specialised assistance in order to help such patients and agencies within the healthcare system to which to refer them. This was all lacking in this particular sad set of circumstances. The court was informed about a proposed pilot scheme – a substance misuse Locally Enhanced Service for people with dependence to prescribed opiates. There was no assurance that this had commenced or indeed yet been funded. I would like an assurance that this hopeful initiative has got off the ground and indeed I would like to have information about any other initiatives to endeavour to address this dreadful problem. I would also like to hear what strides have been taken to improve training and education for general practitioners and GP practices in this worrying area of 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 specialised assistance and referral agencies for general practitioners supporting patients dependent on prescribed opiates
Wider context from the report “The General Practitioner who gave evidence told the court that there was a lacuna in the healthcare provided for patients such as the deceased in terms of giving assistance for weaning off addictive prescription drugs such as opiates . It was clear that General Practitioner’s require highly specialised assistance in order to help such patients and agencies within the healthcare system to which to refer them . This was all lacking in this particular sad set of circumstances . The court was informed about a proposed pilot scheme – a substance misuse Locally Enhanced Service for people with dependence to prescribed opiates. There was no assurance that this had commenced or indeed yet been funded . I would like an assurance that this hopeful initiative has got off the ground and indeed I would like to have information about any other initiatives to endeavour to address this dreadful problem. I would also like to hear what strides have been taken to improve training and education for general practitioners and GP practices in this worrying area of care.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request NICE guidance on safe prescribing of dependence-associated medicines and careful withdrawal management.
Verbatim wording from the response “In addition, the Department asked the National Institute for Health and Care Excellence (NICE) to develop guidance on the safe prescribing of drugs associated with dependence” Source location 2019-0369-Response-from-the-Department-of-Health-and-Social-Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Postgraduate GP training curricula are set by royal colleges and faculties, with GMC approval of curricula and assessment systems.
Verbatim wording from the response “The curricula for postgraduate specialty training, which includes training for GPs, is set by individual royal colleges and faculties, and the GMC approves curricula and assessment systems for each training programme. Training curricula for doctors emphasise the skills and approaches that a doctor must develop in order to ensure accurate and timely diagnoses and treatment plans for their patients.” Source location 2019-0369-Response-from-the-Department-of-Health-and-Social-Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specialised services for people dependent on prescription medicines are the responsibility of local commissioners.
Verbatim wording from the response “Finally, the provision of specialised services to support people dependent on prescription medicines is a matter for local commissioners. I am aware that the Mid-Essex Clinical Commissioning Group (CCG) has responded to your report explaining the services that are in place locally to support patients and GPs. This includes the new Management of Prescribed Opioid Dependence Locally Enhanced Service (referenced in your report), that is anticipated to be in place from 1 April 2020. I am advised that other measures are being taken locally to promote better prescribing and reduce the amount of opioids being prescribed.” Source location 2019-0369-Response-from-the-Department-of-Health-and-Social-Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undergraduate GP education curricula are set by individual medical schools and must meet standards monitored by the GMC.
Verbatim wording from the response “In relation to the education and training of GPs on supporting patients dependent on prescribed medicines, it is for individual medical schools to sets their own undergraduate medical curriculum. These have to meet the standards set by the General Medical Council (GMC), which monitors and checks to make sure that the standards are maintained.” Source location 2019-0369-Response-from-the-Department-of-Health-and-Social-Care
Open published response
6 Nov 2019 Stuart Clarke · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Lack of national referral guidelines for patients with known valvular disease 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
Stuart Clarke · 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
Stuart Clarke presented with breathlessness in February 2018 and underwent a TAVI procedure on 25 June 2019 after a prolonged pathway to treatment. He did not recover following the procedure and died at Wythenshawe Hospital on 27 June 2019. The principal concern was the absence of national guidelines for referral between primary, secondary and tertiary care for patients with known valvular disease, alongside concern about the timeliness of intervention.
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 referral guidelines for patients with known valvular disease
Wider context from the report “However, I was concerned that there remain no national guidelines for referral from primary care to secondary care and/or from secondary care to tertiary care for patients with known valvular disease .
” Open source report
24 Oct 2019 Douglas Paul Oak · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 9 Lack of general awareness of Acute Behavioural Disturbance View source Insufficient frequency and variety of ABD training View source Unsuitability of existing ABD training package for control-room staff View source Failure of Emergency Services to use mutually understood control-room terminology View source Insufficient ABD training for Police and Ambulance Service front-line and control-room staff View source Confusion over Police procedures for requesting Ambulance support View source Absence of Clinical Governance Boards in Police Forces View source Lack of cross-working within the emergency services View source Absence of joint national guidance on Police and Ambulance Service management of ABD View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Douglas Paul Oak · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 11 April 2017, Douglas Paul Oak displayed erratic and frantic behaviour in Poole and was restrained by police after presenting with symptoms of Acute Behavioural Disturbance (ABD). An ambulance request was initially categorised as Category 3, and Douglas went into cardiac arrest before paramedics arrived; he died in hospital the following day. The report raised concerns about inadequate awareness and training on ABD, the lack of national guidance for police and ambulance services, ambulance call prioritisation, sedation, and communication between emergency 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 Lack of general awareness of Acute Behavioural Disturbance
Wider context from the report “i. There is a lack of awareness generally regarding ABD and I would request consideration is given to the inclusion of the signs, symptoms and management of ABD within the First Aid Manual so that all those trained in first aid are able to deal with a patient presenting with ABD.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 frequency and variety of ABD training
Wider context from the report “iv. I also have concerns in relation to the frequency of the delivery of the training referred to in (iii) and I therefore request consideration be given to that training being delivered regularly, at least on an annual basis and with a variety of training techniques, including simulation and role play scenarios.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unsuitability of existing ABD training package for control-room staff
Wider context from the report “vii. In relation to the training package that has been provided by the College of Policing regarding ABD, although ████████ has recommended this could be rolled out to control room staff, the package is tailored for front-line staff . I would therefore request consideration is given to a specific training package on ABD being designed and rolled out to those working in the control room environment by the College of Policing together with the Association of Ambulance Chief Executives or the National Ambulance Service Medical Directors.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Emergency Services to use mutually understood control-room terminology
Wider context from the report “v. Given that the Police and Ambulance Services work very closely in treating and managing a patient with ABD, and other patients who present with life threatening conditions, it is important that they understand each other. It was clear from this Inquest that there is different terminology used by the different services, the meaning of which is not understood by the other Emergency Services . An example of this was the use of the phrase “on the hurry up”. Although the confusion regarding this terminology was not found to be causative or contributory to Doug’s death, it could be in respect of a future death. I therefore request that consideration is given to the joint national training packages for all Emergency Services, namely the Police Service, Ambulance Service and the Fire Service on the workings within each control room and around the language used in the control rooms.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient ABD training for Police and Ambulance Service front-line and control-room staff
Wider context from the report “iii. I believe it is likely there are persons working within Ambulance Service Trusts and Police Forces, whether it be on the front line or in the control room who are not aware of ABD and the serious risk to life it presents . I therefore request that consideration is given to ensuring all those working on the front line, or in control rooms in Ambulance Service Trusts and Police Forces in England and Wales are trained in ABD.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Confusion over Police procedures for requesting Ambulance support
Wider context from the report “ix. It was clear from the evidence that there appears to be confusion of when Dorset Police Officers should call 999 directly and when they should request assistance through the Police control room . I would request that there is consideration of the redrafting of the current “Police Requesting Ambulance Support” policy within Dorset Police and specifically when Police Officers should dial 999. In addition, I would request consideration of training be provided by Dorset Police to all Police Officers regarding the use of dialling 999 when contacting other Emergency Services. In doing this I would ask that consideration is given to liaising with the other local emergency services regarding their expectations, especially SWAST.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Clinical Governance Boards in Police Forces
Wider context from the report “viii. Evidence was given that Dorset Police have established a Clinical Governance Board which helps to create an awareness of, and improvement in, medical care provided by those working in the Police Service. This is not something adopted by all Police Forces in England and Wales and I therefore request that consideration is given to setting up a Clinical Governance Board in every Police Force in England and Wales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of cross-working within the emergency services
Wider context from the report “vi. Extending this point further, evidence was given that there would be benefit in cross working within the emergency services , so for example an Ambulance Clinician working within the Police control room to provide advice. I would therefore request that consideration is given on a national level to cross working within the emergency services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 joint national guidance on Police and Ambulance Service management of ABD
Wider context from the report “ii. There is no joint national guidance on the management of ABD by those who work for the Police and Ambulance Services, both on the front-line and in the control rooms. They are the people most likely to encounter those suffering with ABD and in most cases work together in the management of these patients. Accordingly, I request consideration is given to providing joint national guidance on the management of ABD patients by the Police and Ambulance Services to include:
• the provision of chemical sedation in pre-hospital care
• the training of all paramedics in administering chemical sedation
• the categorisation of Emergency Service calls relating to ABD
• the transfer of an ABD patient to hospital
” Open source report
22 Oct 2019 Nigel Byron Abbott · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 10 Inadequacy of the Home Treatment Standard Operational Procedure for initially assessed and detainable patients awaiting a bed in the community View source Failure to learn and correct identified unsafe beliefs about section 135 warrants View source Mental health professionals operating caseloads well in excess of recommended levels View source Failure of agencies to work together effectively View source Failure to use section 4 for urgent cases View source Failure to provide section 140 beds View source Misunderstanding of the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments View source Chronic shortage of psychiatric beds View source Failure of agencies to work together effectively on mental health detention processes View source Misunderstanding between agencies about urgent section 135 warrant requirements View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Nigel Byron Abbott · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 27 July 2018, Nigel Byron Abbott was killed in a sustained assault by a man experiencing an acute psychotic episode who had been identified as posing a threat of violence but was not detained after mental health beds were reported to be unavailable. The report raised concerns about agencies misunderstanding the urgent use of section 135 powers and failing to work together effectively, potentially leaving acutely unwell people who pose risks to themselves or others unnecessarily free in public.
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 Inadequacy of the Home Treatment Standard Operational Procedure for initially assessed and detainable patients awaiting a bed in the community
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to learn and correct identified unsafe beliefs about section 135 warrants
Wider context from the report “It appears on the current evidence that there is a misunderstanding between the agencies as to how section 135 Mental Health Act 1983 can work in an urgent situation. This includes both whether or not WMP need 24 hours’ notice and whether or not a bed first needs to be available. All agencies need to urgently review the ‘Joint Memorandum of Understanding For Mental Health Professionals Requesting Police Assistance With Mental health Act Assessments and s135(1) & (2) Warrants, June 2018’ and their own practices both individually and jointly to ensure that all staff working in this area understand what is achievable and how.
The context for this report is:
(1) The evidence from WMP is that they do not require 24 hours’ notice to execute a section 135 warrant, whereas the AMHPs (BCC) are of the view there was no point in applying for a section 135 warrant because WMP need 24 hours’ notice.
(2) BSMHFT have stated that BCC refused to co-operate with their Root Cause Analysis process, reviewing what lessons could be learnt from the incident.
(3) I was only made aware that BCC had conducted an Internal Management Review Report - that acknowledged AMHPs were fixed on the operational difficulties of applying for the warrant out of hours and police availability as they required 24 hours’ notice – by a witness on day 1 of the inquest. BCC had not volunteered this report existed.
(4) The BCC Internal Management Review Report – which is designed to be the ‘organisational learning process’ - confirms that BCC has not learnt lessons from the incident effectively. In the action plan there is no mention of the incorrect belief amongst AMHPs, that WMP require 24 hours’ notice, having been corrected .
My on-going concern is that the agencies involved in this area are not working together effectively. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Mental health professionals operating caseloads well in excess of recommended levels
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of agencies to work together effectively
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to use section 4 for urgent cases
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used .
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide section 140 beds
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT .
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Misunderstanding of the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments .
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Chronic shortage of psychiatric beds
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds .
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of agencies to work together effectively on mental health detention processes
Wider context from the report “It appears on the current evidence that there is a misunderstanding between the agencies as to how section 135 Mental Health Act 1983 can work in an urgent situation. This includes both whether or not WMP need 24 hours’ notice and whether or not a bed first needs to be available. All agencies need to urgently review the ‘Joint Memorandum of Understanding For Mental Health Professionals Requesting Police Assistance With Mental health Act Assessments and s135(1) & (2) Warrants, June 2018’ and their own practices both individually and jointly to ensure that all staff working in this area understand what is achievable and how.
The context for this report is:
(1) The evidence from WMP is that they do not require 24 hours’ notice to execute a section 135 warrant, whereas the AMHPs (BCC) are of the view there was no point in applying for a section 135 warrant because WMP need 24 hours’ notice.
(2) BSMHFT have stated that BCC refused to co-operate with their Root Cause Analysis process , reviewing what lessons could be learnt from the incident.
(3) I was only made aware that BCC had conducted an Internal Management Review Report - that acknowledged AMHPs were fixed on the operational difficulties of applying for the warrant out of hours and police availability as they required 24 hours’ notice – by a witness on day 1 of the inquest. BCC had not volunteered this report existed.
(4) The BCC Internal Management Review Report – which is designed to be the ‘organisational learning process’ - confirms that BCC has not learnt lessons from the incident effectively. In the action plan there is no mention of the incorrect belief amongst AMHPs, that WMP require 24 hours’ notice, having been corrected.
My on-going concern is that the agencies involved in this area are not working together effectively . The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Misunderstanding between agencies about urgent section 135 warrant requirements
Wider context from the report “It appears on the current evidence that there is a misunderstanding between the agencies as to how section 135 Mental Health Act 1983 can work in an urgent situation . This includes both whether or not WMP need 24 hours’ notice and whether or not a bed first needs to be available . All agencies need to urgently review the ‘Joint Memorandum of Understanding For Mental Health Professionals Requesting Police Assistance With Mental health Act Assessments and s135(1) & (2) Warrants, June 2018’ and their own practices both individually and jointly to ensure that all staff working in this area understand what is achievable and how.
The context for this report is:
(1) The evidence from WMP is that they do not require 24 hours’ notice to execute a section 135 warrant, whereas the AMHPs (BCC) are of the view there was no point in applying for a section 135 warrant because WMP need 24 hours’ notice.
(2) BSMHFT have stated that BCC refused to co-operate with their Root Cause Analysis process, reviewing what lessons could be learnt from the incident.
(3) I was only made aware that BCC had conducted an Internal Management Review Report - that acknowledged AMHPs were fixed on the operational difficulties of applying for the warrant out of hours and police availability as they required 24 hours’ notice – by a witness on day 1 of the inquest. BCC had not volunteered this report existed.
(4) The BCC Internal Management Review Report – which is designed to be the ‘organisational learning process’ - confirms that BCC has not learnt lessons from the incident effectively. In the action plan there is no mention of the incorrect belief amongst AMHPs, that WMP require 24 hours’ notice, having been corrected.
My on-going concern is that the agencies involved in this area are not working together effectively. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
” Open source report
15 Oct 2019 Mr Derek Weaver · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1 Lack of capacity for regional referrals during surges View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Derek Weaver · 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 Derek Weaver was admitted to hospital with community-acquired pneumonia and an empyema, which required surgery. He died on 31 May 2018 after becoming septic and developing a systemic inflammatory response following delayed transfer for surgery. The principal concern was that the 14-day transfer delay, related to exceptional pressure on bed capacity, contributed to his death and that similar risks could recur during referral surges without additional 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 capacity for regional referrals during surges
Wider context from the report “A consultant thoracic surgeon who was involved in his care after transfer said that had a higher chance of death because surgery was at a time of SIRS. If he had been transferred earlier he would have had surgery when he was not septic. It would have been two stages, the first being key hole surgery, with mortality of only 1 in 100. That may have obviated the necessity of second stage decortication surgery, with mortality of 5%, but it was probably needed anyway. The delay in transfer related to a surge in referrals, limiting capacity. Most regional referrals of this sort needed to be treated at weekends to maintain treatment of cancer cases in the week. There had been pressure to secure greater resources. The risk of potentially preventable deaths will recur whenever there is such a surge in referrals and be mitigated by provision of more beds.
” 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 Peer review and surveillance identified no serious quality or safety concerns in London thoracic services.
Verbatim wording from the response “I am advised that NHS England’s national Specialised Commissioning Quality Team has undertaken peer review and surveillance activities of thoracic services in London, including at the Guy’s and St Thomas’ NHS Foundation Trust where no serious quality or safety concerns were identified. I am further advised that NHSEI will maintain oversight to ensure patients requiring thoracic surgery can access the service in a timely way, according to their clinical condition. This will include reviews of bed capacity in response to the ambition set out in the NHS Long Term Plan, for earlier and faster diagnosis of cancer¹ and the impact this might have on related services such as critical care beds.” Source location 2019-0345-Response-from-the-Department-of-Health
Open published response
10 Oct 2019 Abdeslam BENELGHAZI · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Unsafe co-prescribing of clonazepam with methadone View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Abdeslam BENELGHAZI · 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
Abdeslam BENELGHAZI was detained under Section 2 of the Mental Health Act and was prescribed methadone alongside several other medications, including clonazepam. He died on 9 December 2017; the inquest identified concerns about inappropriate combined prescribing, inadequate monitoring and failure to escalate concerns, including after signs of over-sedation or reduced consciousness.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unsafe co-prescribing of clonazepam with methadone
Wider context from the report “He expressed a particular concern in relation to the prescribing of clonazepam with methadone . The reasons he gave were that clonazepam has a long half life; side effects include respiratory depression ; that one supplier of clonazepam states “concomitant use of clonazepam with opioids may result in sedation, respiratory depression, coma and death ”; that clonazepam is a means of delivering a high equivalent dose benzodiazepine without exceeding BNF limits .
He said that in this case clonazepam may have been the drug that tipped the balance.
” 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 Remind healthcare professionals through a Drug Safety Update article about respiratory-depression risks when benzodiazepines and opioids are co-prescribed.
Verbatim wording from the response “In addition, the MHRA will remind healthcare professionals of the risks of respiratory depression when benzodiazepines and opioids are co-prescribed via an article in its Drug Safety Update early this year.” Source location 2019-0337-Response-by-Department-of-Health-and-Social-Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop prescribing guidance for mental health, endorsed by the Royal Pharmaceutical Society, with additional support, resources and learning materials.
Verbatim wording from the response “I am further advised that HEE is providing education and training opportunities for mental health practitioners through the development of related competency frameworks and teaching initiatives. HEE is working with health system stakeholders, subject matter experts and people with lived experience, to develop guidance, endorsed by the Royal Pharmaceutical Society, that sets out additional guidance, support, resources and learning materials specifically related to prescribing in mental health.” Source location 2019-0337-Response-by-Department-of-Health-and-Social-Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure development of a mental-health early-warning-score case study covering opioid use and over-sedation.
Verbatim wording from the response “In response to changes to the National Early Warning Score (NEWS) parameters¹¹, Health Education England (HEE) is working in partnership with NHS England and NHS Improvement and others, to support learning needs for the health and care workforce. Learning resources have either been developed, are in development or are being planned for staff working in secondary care, primary care, ambulance settings and mental health settings. The resources consist of a number of case studies covering presentations common to particular care settings. In response to your report, HEE advises that it will ensure the development of a specific case study to cover opioid use and over sedation when it develops the early warning score learning resource for mental health settings.” Source location 2019-0337-Response-by-Department-of-Health-and-Social-Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request marketing authorisation holders to update clonazepam and methadone product information, including warnings about respiratory depression and delayed methadone effects.
Verbatim wording from the response “The MHRA has reviewed all licences for clonazepam and methadone and noted that not all marketing authorisation holders (MAH) have applied the appropriate amendments. The MHRA is therefore contacting the MAH holders to request updates to the product information and the outstanding changes are expected to be implemented within three to six months.” Source location 2019-0337-Response-by-Department-of-Health-and-Social-Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clinicians are responsible for prescribing decisions, including medication dosages and combinations.
Verbatim wording from the response “Prescribing decisions are made by clinicians who are responsible for taking into consideration the dosage of medication prescribed and the combination of medicines administered.” Source location 2019-0337-Response-by-Department-of-Health-and-Social-Care
Open published response
9 Oct 2019 James Frankish · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Failure of professionals caring for people with Pica to understand its health risks View source Lack of national or professional guidance on identification, assessment and management of Pica and its risks View source Lack of national or professional guidance for monitoring bezoar development in people with Pica 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
James Frankish · 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 Frankish died at Beeches Residential Home after vomiting plant material and expelling a hard plant mass from his stomach into his oesophagus, causing sudden obstruction. The principal concerns were that professionals and care staff did not fully understand or manage the dangers of Pica, and that national or professional guidance was lacking on identifying, assessing and managing Pica and monitoring for bezoar development.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of professionals caring for people with Pica to understand its health risks
Wider context from the report “(1) Professionals who cared for James did not understand how dangerous Pica can be , ie that it carries significant health risks, including the development of a bezoar . This included the GP, Paediatrician, Psychiatrist, Speech and language therapist, Clinical Psychologist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 or professional guidance on identification, assessment and management of Pica and its risks
Wider context from the report “(2) That there is no national or professional guidance about identification, assessment and management of Pica , with no guidance about how best to understand and manage risk in this condition
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national or professional guidance for monitoring bezoar development in people with Pica
Wider context from the report “(3) That there is no national or professional guidance for monitoring for the possible development of a bezoar in an individual who has Pica .
” Open source report
5 Oct 2019 Master Alex Malcolm · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Inadequate arrangements for responding to domestic violence View source Difficulties in recruitment and retention of probation officers View source Insufficient availability of Approved Premises places 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
Master Alex Malcolm · 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
Master Alex Malcolm, aged 5, died on 22 November 2016 from a head injury and was found to have been unlawfully killed; a perpetrator was convicted of murder. The jury identified concerns including the perpetrator’s misclassification, failures to share information and safeguard the deceased’s mother, inadequate probation supervision, failure to secure approved premises, and failures to respond to licence breaches. Further concerns included shortages of approved premises, domestic-violence safeguarding arrangements, and recruitment and retention difficulties among probation officers.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate arrangements for responding to domestic violence
Wider context from the report “2. The Chair of the Serious Case Review subgroup of Lambeth Safeguarding Children Board said that strengthening any arrangements around domestic violence , including putting MARACs on a statutory basis had the potential to save lives. The senior Coroner raised this issue in a Prevention of Future Deaths Report to the Secretary of State for Health earlier this year, triggered by the chair of a domestic homicide review into the death of Donna Williamson. Her evidence was clear that there were arguments for MARAC and other bodies to be put on a statutory footing and for the system to be reviewed . The response from the ministry did not specifically address the issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Difficulties in recruitment and retention of probation officers
Wider context from the report “3. A senior NPS divisional head said that there were still difficulties in recruitment and retention of probation officers , one factor in which was low pay. It is understood the matter is under review but details of what steps have since been taken and their adequacy were not heard by the coroner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of Approved Premises places
Wider context from the report “1. A senior NPS divisional head said that providing more Approved Premises places would potentially save lives . It is understood the matter is under review but details of what steps have since been taken were not heard by the coroner.
” Open source report
1 Oct 2019 Oliver Sharp · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure of schools to recognise risks and early signs associated with acceleration ahead of chronological school age View source Additional challenge associated with disability labelling for ageing children with autism View source Long waiting lists for autism assessments View source Variation and limited transition provision in post-16 mental health services View source See 1 more concern
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Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Oliver Sharp · 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
Oliver Sharp died after taking a fatal dose of heroin; his death was confirmed at Wythenshawe Hospital on 18 October 2018. The inquest identified concerns about failures by mental health services to recognise and respond to his increasing level of risk during his transition from child and adolescent mental health services to reduced post-16 provision, as well as concerns about delays in autism assessment and variation in post-16 services.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of schools to recognise risks and early signs associated with acceleration ahead of chronological school age
Wider context from the report “During the inquest evidence was heard that acceleration ahead of a chronological school age might cause relatively few difficulties in peer relationships up to about year 9 but post that as children entered adolescence it could become a significant issue impacting a child’s mental health and ability to cope . Where it did happen, there needed to be an understanding by schools of the risks and early signs indicating a need for additional support to try to reduce the likelihood of self-harming behaviours and the potential need for additional support.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Additional challenge associated with disability labelling for ageing children with autism
Wider context from the report “The inquest heard that Oliver had found the autism label and the label of disability that was attached to it very difficult to accept as time went on . There was evidence that particularly with ageing children with autism the idea that they had a disability created additional challenge .
The language that it would have been more helpful to use widely would have been difference rather than disability.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Long waiting lists for autism assessments
Wider context from the report “The inquest was told that it is important for autism to be diagnosed as early as possible so that appropriate support can be put in place. Early diagnosis was impacted by a national picture of long waiting lists for ADOS assessments . In Stockport there was approximately a 6 month waiting list for assessment . This was against a national picture of 12-24 month waits in some areas .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Variation and limited transition provision in post-16 mental health services
Wider context from the report “The inquest was told that the provision of mental health services post 16 varies widely across the country . In some areas there is a CAMHS 16-25 mental health service provision similar to the national 16 and under service whereas in other areas there a limited transition service or move back to primary care for re-referral to adult services . The inquest was told that this creates a cliff edge high risk situation for adolescents . The reason for the difference was resources and decisions taken by CCGs.
” Open source report
30 Sep 2019 Charles Williamson · Prevention of Future Deaths report Manchester South
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Concerns raised 1 Insufficient availability of appropriate neuro-rehabilitation beds in Greater Manchester View source
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AI-generated summary
Charles Williamson · 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
Charles Williamson sustained a traumatic brain injury after falling in Portugal and underwent treatment and rehabilitation in several hospitals. He later developed infections and deteriorated; the report raised concern that a shortage of appropriate neuro-rehabilitation beds in Greater Manchester could delay effective rehabilitation and increase the risk of complications leading to death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of appropriate neuro-rehabilitation beds in Greater Manchester
Wider context from the report “The inquest heard that following neurological incidents such as those sustained by Mr Williamson it will often be the case that a key to returning to baseline or closer to baseline is effective and early neuro-rehabilitation. The inquest was told that a shortage of appropriate neuro-rehabilitation beds in Greater Manchester was in some cases preventing early effective neuro-rehabilitation and increasing the risk of complications which could lead to death.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local NHS commissioners are responsible for providing neuro-rehabilitation services in Greater Manchester.
Verbatim wording from the response “The provision of neuro-rehabilitation services in Greater Manchester is a matter for local NHS commissioners. The Greater Manchester Health and Social Care Partnership (GMHSCP) was formed in 2016, bringing together local authorities, NHS commissioners, NHS providers and the Mayoral Combined Authority to oversee the health and social care devolution programme in Greater Manchester. The GMHSCP has control of a £6 billion health and social care budget that is used to provide integrated care.” Source location 2019-0326-Response-from-the-Department-of-Health-and-Social-Care
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30 Sep 2019 Julie Ann Barrow · Prevention of Future Deaths report Manchester South
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Concerns raised 8 Failure to provide trauma-informed hospital care View source Failure to hold best interests meetings to discuss inpatient care View source Reduced safeguarding team capacity to support people with learning disabilities in hospital View source Failure to put in place a reasonable adjustments care plan View source Unavailability of a learning disability liaison role within the hospital View source Failure to communicate effectively with the patient and understand her needs View source Failure to make the needs passport accessible to all staff caring for the patient View source Failure to provide suitable overnight accommodation for essential family carers View source See 5 more concerns
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Julie Ann Barrow · 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 Ann Barrow, who had significant learning disabilities, was admitted to hospital on several occasions for perianal pain, rectal bleeding and haemorrhoids. Following treatment for adjustment disorder and significant sedation, she fell at her family home on 1 April 2019, sustained an unsurvivable brain injury and died in hospital the next day. The principal concerns included the absence of a best interests meeting and reasonable adjustment care plan, ineffective communication and understanding of her needs, inadequate support for her parents, and the loss of the learning disability liaison role.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide trauma-informed hospital care
Wider context from the report “3. Julie Ann Barrow was cared for devotedly in hospital by her parents who are in their 80s. Their evidence to the inquest was that Julie was never effectively communicated with by clinicians treating her and her needs not understood. So far as her needs were concerned she was “invisible” to staff. An approach that recognised just how traumatic a hospital stay and medical treatment was for her would have significantly reduced the trauma that led to her developing adjustment disorder. The consultant psychiatrist who gave evidence to the inquest was very clear that the pain and trauma of the hospital stays had caused the acute adjustment disorder;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 best interests meetings to discuss inpatient care
Wider context from the report “1. The inquest heard that despite two in-patient stays, there was no best interests meeting held to discuss her 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 Reduced safeguarding team capacity to support people with learning disabilities in hospital
Wider context from the report “5. The inquest was told by the safeguarding team that cuts by the Local Authority had resulted in the loss of the learning disability liaison role, had reduced the ability of the safeguarding team to support people with learning disabilities within the 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 put in place a reasonable adjustments care plan
Wider context from the report “2. On each of her admissions her parents took her needs passport in with her. The inquest was told that this should be used to develop the reasonable adjustments care plan and be accessible to all staff caring for her. On her first admission there was no reasonable care plan put in place despite the fact that she had clear and significant disabilities that would have benefited from an effective plan and her passport was available. Her passport location was not known by all staff caring for 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 Unavailability of a learning disability liaison role within the hospital
Wider context from the report “5. The inquest was told by the safeguarding team that cuts by the Local Authority had resulted in the loss of the learning disability liaison role , had reduced the ability of the safeguarding team to support people with learning disabilities within the 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 communicate effectively with the patient and understand her needs
Wider context from the report “3. Julie Ann Barrow was cared for devotedly in hospital by her parents who are in their 80s. Their evidence to the inquest was that Julie was never effectively communicated with by clinicians treating her and her needs not understood . So far as her needs were concerned she was “invisible” to staff . An approach that recognised just how traumatic a hospital stay and medical treatment was for her would have significantly reduced the trauma that led to her developing adjustment disorder. The consultant psychiatrist who gave evidence to the inquest was very clear that the pain and trauma of the hospital stays had caused the acute adjustment disorder;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 the needs passport accessible to all staff caring for the patient
Wider context from the report “2. On each of her admissions her parents took her needs passport in with her. The inquest was told that this should be used to develop the reasonable adjustments care plan and be accessible to all staff caring for her. On her first admission there was no reasonable care plan put in place despite the fact that she had clear and significant disabilities that would have benefited from an effective plan and her passport was available. Her passport location was not known by all staff caring for her ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide suitable overnight accommodation for essential family carers
Wider context from the report “4. Her parents stayed with her 24/7 to try and support her and reduce the trauma. Despite their age, their importance to her and the need for them to stay with her, staff at the trust expected them to sleep overnight on standard hospital bedside chairs . It was only when a complaint was escalated that attempts were made to find them alternatives to the chair;
” 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 Consult on introducing mandatory learning disability and autism training for health and care staff.
Verbatim wording from the response “Local LeDeR reviews have also demonstrated that health and social care staff do not always have the skills and knowledge to provide effective, compassionate and safe care to people with learning disabilities. For this reason, we have consulted on the introduction of mandatory learning disability and autism training for health and care staff.” Source location 2019-0325-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 Amend regulations to require regulated health and social care providers to ensure staff receive relevant learning disability and autism training.
Verbatim wording from the response “To mandate the training, we will amend the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014⁶, to require NHS and social care providers carrying out regulated activities to ensure that their staff have relevant levels of training in learning disability and autism. Other levers will be used to mandate training for staff working in non-regulated activities.” Source location 2019-0325-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, test and evaluate a Tier 2 learning disability and autism training package to inform final design and wider rollout.
Verbatim wording from the response “For Tier 2 training we will develop and test a learning disability and autism training package through 2020/21 in a number of geographical and service settings. We will undertake an evaluation of the training package to inform the final design of training and wider roll out.” Source location 2019-0325-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 Publish proposals for training health and social care staff consistently with the two Core Capability Frameworks.
Verbatim wording from the response “In the Government’s response to the consultation⁴, published on 5 November 2019, we set out a series of proposals that will ensure that health and social care staff will, over time, receive training consistent with the Core Capability Frameworks for People with a Learning Disability and Supporting Autistic People⁵.” Source location 2019-0325-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 Use additional mechanisms to mandate learning disability and autism training for staff working in non-regulated activities.
Verbatim wording from the response “To mandate the training, we will amend the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014⁶, to require NHS and social care providers carrying out regulated activities to ensure that their staff have relevant levels of training in learning disability and autism. Other levers will be used to mandate training for staff working in non-regulated activities.” Source location 2019-0325-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 Work with professional bodies and devolved Administrations to align pre-registration training with the Core Capability Frameworks and develop a common curriculum.
Verbatim wording from the response “These Frameworks set out the core skills and knowledge that staff supporting people with a learning disability or autism should have, depending on the nature and intensity of care or support they give. This will ensure that staff have the skills and knowledge that are appropriate to their role. In this regard, we will work with professional bodies and the devolved Administrations to align pre-registration training as closely as possible with the two Core Capability Frameworks and work towards a common curriculum for pre-registration training in due course.” Source location 2019-0325-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 Local authorities, rather than central government, determine how additional funding is used to support adult social care services.
Verbatim wording from the response “With full take-up of the social care precept⁷ in 2019/20, based on their previous decisions, Stockport Council could receive a total of £52.8million additional funding between 2017/18 and 2019/20⁸. It is for local authorities to determine how this funding is used to support adult social care services.” Source location 2019-0325-Response-from-The-Department-of-Health-and-Social-Care
Open published response
30 Sep 2019 Owen Carey · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Lack of statutory requirements for the appearance of restaurant allergen notices View source Lack of complete allergen information on the face of restaurant menus View source Lack of a national register of severe food anaphylactic reactions View source Inadequate allergen training for serving staff View source Insufficient prominence of allergen notices on restaurant menus View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Owen Carey · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 22 April 2017, Owen Carey ate food at Byron restaurant at the O2 centre despite making serving staff aware of his dairy allergy. The chicken contained buttermilk, causing a severe food-induced anaphylactic reaction from which he died. Concerns included the adequacy of allergen training, the prominence and effectiveness of allergen notices and information on menus, and the absence of a national register for severe food anaphylactic reactions.
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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 statutory requirements for the appearance of restaurant allergen notices
Wider context from the report “(2) The effectiveness of the current placement and appearance of allergen notices on restaurant menus to trigger an allergen discussion between a customer and serving staff: I was told, and accept, that it was more important to trigger a discussion between a customer and member of serving staff about allergens than to have a menu which included complete allergen information on its face. However, the prompt for this discussion on the Byron O2 menu at the time was: (i) on the side of the menu which appeared to focus solely on a ‘special’, namely a Kim Cheese burger, (ii) at the very bottom and distant from all the main food options, (iii) in very small font and (iv) on a royal blue background in black ink. I was told that this placement and appearance was not outwith the ‘general approach of the restaurant industry as a whole and that the current Food Information Regulations did not, unlike with prepacked food, specify the location and / or font size and / or prominence of such an allergen notice. It concerns me that such little prominence appears to be given industry wide to a notice which is intended to trigger what could potentially be a lifesaving discussion between a customer and member of serving staff. It further concerns me that there are no statutory requirements regarding the appearance of such an allergy notice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 complete allergen information on the face of restaurant menus
Wider context from the report “(3) The lack of key allergen information on the face of restaurant menus and therefore their potential to be falsely reassuring: In my findings I concluded that Owen and his brother would have been falsely reassured with the menu description of Owen's order because on its face the Byron O2 menu in place at the time did not readily identify that the chicken would have been marinated in buttermilk or at all. I was shown a more up to date menu from Byron O2 and note that where buttermilk is now used to marinate chicken it is identified. However, the prompt for this change was one of ‘food fashion’ I was told rather than a move to make the menu more allergen friendly. Although I accept that triggering a discussion between a customer and member of serving staff about allergens is of key importance (as indicated above), the absence of any simple allergen words or symbols on the face of a restaurant menu is of concern , particularly when one takes into account (i) what I was told about the latest figures demonstrating how a significant proportion of customers may be naturally shy/ reluctant about sharing their allergies with serving staff and (ii) that restaurants, like Byron O2, tend to attract younger diners dining alone (i.e. school age children without their parents). It also concerns me that at the time there were symbols on the menu depicting the use of peanuts, but not other allergen , which in my view could also have potentially falsely reassured diners that allergens were being identified on the face of the menu when in fact they were not .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a national register of severe food anaphylactic reactions
Wider context from the report “(4) The lack of a national register recording severe food anaphylactic reactions: I was told in evidence that despite faster ambulance response times, a greater awareness of allergies and a greater distribution of epi-pens that the death rate for severe food anaphylaxis remains static and that this is attributed in part to the fact that little is known about these deaths because thus far there has been a failure to collect together any learning from these tragedies . It concerns me that there is therefore no national register recording the circumstances of these deaths which could then be analysed and learnt from by allergy specialists .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 allergen training for serving staff
Wider context from the report “(1) The adequacy and effectiveness of allergen training at Byron O2: My findings included that there must have been a human error by a member of Byron O2 serving staff at the point of ordering. The training provided to serving staff regarding allergens at Byron O2 was limited to a combination of staff members simply attesting to the fact that they had read the company's training on allergen information and no more, coupled with an “on the job” induction in respect of which no records or details existed. It was accepted in evidence that Byron O2 had a high turnover of serving staff. This, I was told and accept, is common for the restaurant industry overall, who often rely, for example on seasonal workers. I was not confident that the current approach to allergen training about which I heard evidence was effective and / or would engage the less diligent employee , which any organisation will have, and which are potentially in a greater proportion where there is high staff turnover.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 prominence of allergen notices on restaurant menus
Wider context from the report “(2) The effectiveness of the current placement and appearance of allergen notices on restaurant menus to trigger an allergen discussion between a customer and serving staff: I was told, and accept, that it was more important to trigger a discussion between a customer and member of serving staff about allergens than to have a menu which included complete allergen information on its face. However, the prompt for this discussion on the Byron O2 menu at the time was: (i) on the side of the menu which appeared to focus solely on a ‘special’, namely a Kim Cheese burger, (ii) at the very bottom and distant from all the main food options, (iii) in very small font and (iv) on a royal blue background in black ink. I was told that this placement and appearance was not outwith the ‘general approach of the restaurant industry as a whole and that the current Food Information Regulations did not, unlike with prepacked food, specify the location and / or font size and / or prominence of such an allergen notice. It concerns me that such little prominence appears to be given industry wide to a notice which is intended to trigger what could potentially be a lifesaving discussion between a customer and member of serving staff. It further concerns me that there are no statutory requirements regarding the appearance of such an allergy notice.
” Open source report
19 Sep 2019 Caspian Thorn · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 9 Delays in reviewing pathological CTG View source Shortage of midwives in the enhanced midwifery team View source Failure to make decisions in accordance with trust guidance View source Failure to recognise early signs of sepsis and clinical deterioration in the NICU View source Lack of clarity about supporting and managing vulnerable families View source Failure to clearly document clinical decision-making in the notes View source Shortage of experienced social workers in the Local Authority View source Lack of communication between midwifery and social work teams View source Failure to document triage calls and advice View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Caspian Thorn · 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
Caspian Thorn was born with significant brain damage after chronic placental insufficiency and died in hospital on 29 September 2018 after developing a gram-negative hospital-acquired infection and sepsis. The concerns included failure to offer induction or follow up a missed growth scan, poor communication and support for a vulnerable family, undocumented triage calls, inadequate documentation of decision-making, delayed recognition of a pathological CTG, and delayed recognition of signs of sepsis.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in reviewing pathological CTG
Wider context from the report “5. The 1st CTG on 24th September was a pathological CTG from the very early stages but was not reviewed until half an hour had elapsed despite the history . An expectation that CTG should be observed for a period of time after first starting would have allowed for earlier identification of fetal distress ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Shortage of midwives in the enhanced midwifery team
Wider context from the report “1. A feature of the evidence was a lack of communication between the teams of midwives and social worker. This meant that it was not picked up that his mother had missed a key fetal growth scan and that a small baby was not monitored for the period between 10th September until his birth on 24th September. The inquest heard that contributing to this was a shortage of midwives in the enhanced midwifery team and a shortage of experienced social workers in the Local Authority at the time;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 decisions in accordance with trust guidance
Wider context from the report “4. Decision making that was not in accordance with trust guidance on 10th September was not clearly documented in the notes;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise early signs of sepsis and clinical deterioration in the NICU
Wider context from the report “6. Early signs of sepsis were not identified by the consultant neonatologist because it was thought the observations reflected a move to warming from cooling. The other experienced staff within the NICU did not appear to recognise a deteriorating position until 12 hours after early signs of deterioration were noted .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 supporting and managing vulnerable families
Wider context from the report “2. Caspian’s family had been identified as vulnerable. There was a lack of clarity about how to effectively support and manage the situation to ensure that there was effective engagement throughout the pregnancy and during delivery;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly document clinical decision-making in the notes
Wider context from the report “4. Decision making that was not in accordance with trust guidance on 10th September was not clearly documented in the notes ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Shortage of experienced social workers in the Local Authority
Wider context from the report “1. A feature of the evidence was a lack of communication between the teams of midwives and social worker. This meant that it was not picked up that his mother had missed a key fetal growth scan and that a small baby was not monitored for the period between 10th September until his birth on 24th September. The inquest heard that contributing to this was a shortage of midwives in the enhanced midwifery team and a shortage of experienced social workers in the Local Authority at the time;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of communication between midwifery and social work teams
Wider context from the report “1. A feature of the evidence was a lack of communication between the teams of midwives and social worker . This meant that it was not picked up that his mother had missed a key fetal growth scan and that a small baby was not monitored for the period between 10th September until his birth on 24th September. The inquest heard that contributing to this was a shortage of midwives in the enhanced midwifery team and a shortage of experienced social workers in the Local Authority at the time;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 triage calls and advice
Wider context from the report “3. There had been two undocumented calls to triage on the morning of 24th September 2018. The inquest heard that when staff were busy on the triage team calls and advice were not always documented ;
” Open source report
12 Sep 2019 William Oliver · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Delays in hospital patient handover causing prolonged ambulance unavailability View source Meal break policy causing crews to become unavailable for call allocation 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
William Oliver · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William Oliver died at home on 1 November 2018 after becoming acutely unwell and contacting emergency services. The report describes concerns about inappropriate handling and re-triage of subsequent calls, ambulance resource availability affected by meal-break rostering and prolonged hospital turnaround times.
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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 Delays in hospital patient handover causing prolonged ambulance unavailability
Wider context from the report “2. Turnaround times at Greater Manchester Hospitals
Another contributing factor to the decreased availability of ambulances on the 31st October - 1st November 2018 was the turnaround times from hospitals in the Greater Manchester area. This was greater than anticipated at numerous sites. Whilst all hospitals were busy the turnaround times at Manchester Royal Infirmary, North Manchester hospital, Royal Oldham, Salford Royal and Stepping Hill hospital were all particularly higher than anticipated with numerous ambulances delayed for over one hour. In total from the commencement of the night shift on the 31st October more than 273 hours of ambulance availability were spent at hospital sites handing over patients. The evidence from NWAS did not suggest this was significantly different to other nights or uncommon.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Meal break policy causing crews to become unavailable for call allocation
Wider context from the report “1. Meal Break Policy and Shift Rostering
During the course of the Inquest the Court heard evidence as to the demand placed on NWAS during the night of the 31st October – 1st November. Difficulties in allocating resources within the Manchester area of the North West that night had been escalated to the Regional Control and Command Centre. One of the reasons for difficulties in allocating resources was directly attributed to the Meal Break Policy. In short, the issue being that each crew has to take a 30 minute meal break within their meal break window (this being three hours after their shift starts). If the crews reach the end of their meal break window without having taken a break they are automatically stood down and are unavailable to allocate calls to. The consequences of this policy have also been highlighted in other investigations following a death. In this case there was a significant reduction in the number of vehicles able to be allocated during the time Mr Oliver had contacted NWAS. The Court heard evidence this policy has been under review for sometime and consideration has been given to staggering the shift start times, but as yet no changes have been implemented
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual ambulance trusts, not national authorities, are responsible for operational meal-break and shift-rostering arrangements, subject to employment law.
Verbatim wording from the response “On the matter of meal breaks and shift rostering, paramedic meal breaks and shift pattern arrangements are operational matters for individual ambulance trusts and there is no national ambulance meal break policy. Meal break requirements are set out in employment law (including the Working Time Directive) and NHS ambulance trusts develop their own policies to ensure compliance with the law.” Source location 2019-0494-Response-by-Department-of-Health-and-Social-Care
Open published response
8 Sep 2019 Reece Tristan Lapina-Amarelle · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 6 Insufficient emphasis on safety and preserving life in the Mental Health Act View source Lack of resources for people with serious mental illness and alcohol or drug misuse histories View source Inability to require access to and cooperation with voluntary substance and alcohol misuse services outside the criminal justice system View source Insufficient information sharing between mental health and substance and alcohol misuse services View source Lack of a treatment system for people with serious mental illness and alcohol or drug misuse histories View source Failure of the Mental Health Act to provide responsibility for an action plan 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
Reece Tristan Lapina-Amarelle · 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
Reece Tristan Lapina-Amarelle, aged 20, died by suicide after being discharged from hospital with the expectation that he would immediately attempt to take his life. The report identifies concerns about insufficient resources and treatment for people with serious mental illness and substance misuse, inadequate information-sharing between services, limitations of voluntary support, and the Mental Health Act's failure to provide an appropriate plan of action focused on safety.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient emphasis on safety and preserving life in the Mental Health Act
Wider context from the report “(5) Twenty years ago the connection between the use of strong drugs in teenage years and subsequent mental health (often very serious) was not fully recognised. However nowadays there is far greater use of drugs which are growing ever stronger, and a very considerable number of people with mental health issues in prison or in the community have developed or worsened their conditions by the use of cannabis and other illegal substances. The Mental Health Act still concentrates on therapy without giving sufficient emphasis, in my view, to safety and, in blunt terms, keeping people alive .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 resources for people with serious mental illness and alcohol or drug misuse histories
Wider context from the report “(1) There are no resources and no system of treatment for people who present with serious mental illness and alcohol or drug misuse histories.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inability to require access to and cooperation with voluntary substance and alcohol misuse services outside the criminal justice system
Wider context from the report “(3) That latter service is voluntary and, outside the criminal justice system, the subject cannot be forced to access and receive help or to cooperate with that 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 Insufficient information sharing between mental health and substance and alcohol misuse services
Wider context from the report “(2) There is insufficient sharing of information between the Mental Health Trust and CGL (the Substance and Alcohol Misuse 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 Lack of a treatment system for people with serious mental illness and alcohol or drug misuse histories
Wider context from the report “(1) There are no resources and no system of treatment for people who present with serious mental illness and alcohol or drug misuse histories .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Mental Health Act to provide responsibility for an action plan
Wider context from the report “(4) In my opinion the Mental Health Act is out of date in that it does not recognise or accept responsibility for providing a plan of action to deal with people such as Reece.
” 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 Publish a White Paper setting out the Government’s full response to the Independent Review of the Mental Health Act.
Verbatim wording from the response “More generally, as you are aware, we commissioned a full and independent review of the Mental Health Act. The Independent Review of the Mental Health Act was published on 6 December 2018⁷. The Review made 154 recommendations. If implemented they would give more legal weight to people’s choices, make the use of compulsion more targeted and transparent, and modernise services to provide patient-centred care which respects the patient’s dignity.” Source location 2019-0274-Response-by-Department-of-Health-and-Social-Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue supporting the “no wrong door” approach for people presenting with co-occurring mental health and substance misuse conditions.
Verbatim wording from the response “The Government continues to support the ‘no wrong door’ approach when people present to services with co-occurring conditions. Commissioning guidance encourages services to respond collaboratively, effectively and flexibly, offering” Source location 2019-0274-Response-by-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 Treatment decisions under the Mental Health Act are matters for healthcare professionals, not specified by the Act.
Verbatim wording from the response “The Act allows for the detention and treatment of people with a mental disorder when there is a concern for a person’s health and safety or that of other people and, where a patient is at risk of suicide, there is an expectation that the Act is used to protect the patient. A practitioner may prefer to try to keep the patient in hospital informally or use the Mental Capacity Act’s Deprivation of Liberty Safeguards to detain the patient. The Act does not, however, set out recommendations for therapy or other treatments, as these are matters for healthcare professionals.” Source location 2019-0274-Response-by-Department-of-Health-and-Social-Care
Open published response
6 Sep 2019 Ms Shannon Quinn · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 7 Failure to adhere to the five-minute patient observation level View source Inconsistent and minimal training for care staff in managing complex patient needs View source Minimal training for care staff in performing patient resuscitation View source Lack of a joint multidisciplinary care plan View source Inconsistent sharing of clinical documentation and care plans between statutory agencies and private-sector care providers View source Insufficient contact with the care coordinator View source Failure to provide a ligature-free environment despite escalating ligature and self-harm risk 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
Ms Shannon Quinn · 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
Ms Shannon Quinn, a 24-year-old woman with a complex mental health history and repeated self-harm, was found hanging in her room at Oak House on 9 January 2019 and was pronounced deceased shortly afterwards. The report identified concerns including inadequate information sharing and joint care planning, insufficient staff training, escalating ligature risk without sufficient environmental measures, and failure to adhere to five-minute observations.
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 adhere to the five-minute patient observation level
Wider context from the report “5. The patient observation level of 5 minutes was introduced to minimise risk of self-harm but not adhered to .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistent and minimal training for care staff in managing complex patient needs
Wider context from the report “2. There was inconsistent and minimal training provided to Oak House staff in respect of managing SQ’s complex needs by the Mental Health 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 Minimal training for care staff in performing patient resuscitation
Wider context from the report “6. Evidence emerged during the inquest that there had been minimal training for Oak House staff in performing resuscitation on patients . The training received included general first aid training by e-learning .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 joint multidisciplinary care plan
Wider context from the report “3. There was a lack of a joint multi-disciplinary/Trust care plan and insufficient contact with the care coordinator due to difficulties in travelling to meet the patient outside the normal Trust area and staff sickness absence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistent sharing of clinical documentation and care plans between statutory agencies and private-sector care providers
Wider context from the report “1. Evidence emerged during the inquest that there was inconsistent sharing of documentation and case notes between the statutory agencies and private sector . In particular, there was no sharing of medical notes/care plans between the Birmingham and Solihull and Mental Health Trust and Oak House .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 contact with the care coordinator
Wider context from the report “3. There was a lack of a joint multi-disciplinary/Trust care plan and insufficient contact with the care coordinator due to difficulties in travelling to meet the patient outside the normal Trust area and staff sickness absence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a ligature-free environment despite escalating ligature and self-harm risk
Wider context from the report “4. There was an escalating risk of use of ligatures and incidents of self-harm and little if any measures were introduced to try and provide a ligature free environment .
” Open source report
16 Aug 2019 Martin Leslie Haines · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 7 Failure to carry out diagnostic testing and monitoring for diabetes View source Fragmentation of responsibility for prison healthcare across multiple organisations View source Standard of care falling below community level View source Failure to confirm cardiovascular disease View source Availability of means to brew or distil alcohol View source Lack of protocols or agreements for responding to an unresponsive body View source Insufficient communication and information sharing between prison healthcare organisations View source See 4 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
Martin Leslie Haines · 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
Martin Leslie Haines was detained at Lewes Prison and was found dead in his cell on 18 March 2018. He had Type II Diabetes and warning signs of cerebrovascular disease, but the appropriate diagnostic tests were not carried out; alcohol, Venlafaxine and Amitriptyline were later found in his system and considered by the pathologist to have contributed to his death. The principal concerns included inadequate diabetes and cardiovascular monitoring, healthcare falling below community standards, the ability to brew or distil alcohol in prison, a lack of protocols for responding to an unresponsive body, and insufficient communication between healthcare providers and the prison service.
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 carry out diagnostic testing and monitoring for diabetes
Wider context from the report “(2) The failure to carry out diagnostic testing and monitoring for his diabetes and to confirm his considerable cardiovascular disease.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Fragmentation of responsibility for prison healthcare across multiple organisations
Wider context from the report “(5) In my opinion, the underlying problems were due to the fact that responsibility for healthcare in the prison was split between the prison service, Sussex Partnership Foundation Trust (which is a mental health provider but was also contracted to run all healthcare, both physical and mental within the prison), Medco Ltd who provided the GPs and Forward Trust who were contracted to treat alcohol and substance misuse in the prison . There was insufficient communication between these bodies and they had separate IT databases.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Standard of care falling below community level
Wider context from the report “(3) The standard of care appears to have fallen well below that which he could have received 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 confirm cardiovascular disease
Wider context from the report “(2) The failure to carry out diagnostic testing and monitoring for his diabetes and to confirm his considerable cardiovascular disease .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Availability of means to brew or distil alcohol
Wider context from the report “(1) The fact that the deceased was able to brew or distil his own alcohol .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of protocols or agreements for responding to an unresponsive body
Wider context from the report “(4) There were no protocols or agreements between healthcare staff and the prison service as to how best to respond to an unresponsive body .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient communication and information sharing between prison healthcare organisations
Wider context from the report “(5) In my opinion, the underlying problems were due to the fact that responsibility for healthcare in the prison was split between the prison service, Sussex Partnership Foundation Trust (which is a mental health provider but was also contracted to run all healthcare, both physical and mental within the prison), Medco Ltd who provided the GPs and Forward Trust who were contracted to treat alcohol and substance misuse in the prison. There was insufficient communication between these bodies and they had separate IT databases .
” 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 Review and improve commissioning and links across health, justice, local authority, probation and community services to align provision before, during and after custody.
Verbatim wording from the response “The Agreement sets out a joined-up, strategic approach to meet the complex nature of offender health care needs and provides the partnership members with an overarching framework for collaborative working at all levels. The Agreement has three shared core objectives to be delivered through ten high level priorities. These priorities are underpinned by the Agreement’s 2018 Workplan, which includes a commitment to deliver on three key issues that relate to the responsibilities of all organisations involved in prison care. These commitments are:” Source location 2019-0486-Response-by-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 Improve health and care data collection and information-sharing before, during and after incarceration to support continuity of care.
Verbatim wording from the response “The Agreement sets out a joined-up, strategic approach to meet the complex nature of offender health care needs and provides the partnership members with an overarching framework for collaborative working at all levels. The Agreement has three shared core objectives to be delivered through ten high level priorities. These priorities are underpinned by the Agreement’s 2018 Workplan, which includes a commitment to deliver on three key issues that relate to the responsibilities of all organisations involved in prison care. These commitments are:” Source location 2019-0486-Response-by-Department-of-Health-and-Social-Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working collaboratively across government to deliver high-quality prison health services and the National Partnership Agreement’s aims.
Verbatim wording from the response “You may be aware that the Health and Social Care Select Committee conducted an inquiry into prison health that reported in November 2018³. The Government’s response, published in January 2019⁴, outlined a range of actions, including those in the National Partnership Agreement, that will be taken to support the delivery of high-quality health services in prisons. We remain committed to working collaboratively across Government to achieve those aims. For example, in response to one of the recommendations, the National Prison Partnership Board published a Principle of Equivalence in October 2019. This states that the co-chairs of the National Prison Healthcare Board affirm that:” Source location 2019-0486-Response-by-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 Revise the prison healthcare partnership agreement to add Department of Health and Social Care and Ministry of Justice oversight and accountability.
Verbatim wording from the response “At a national level, the National Audit Office report into Mental Health in Prisons¹, published in June 2017, made a recommendation in relation to the way that NHS England, Her Majesty’s Prison and Probation Service and Public Health England manage their joint working on prison healthcare.” Source location 2019-0486-Response-by-Department-of-Health-and-Social-Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for commissioning healthcare services for prisoners.
Verbatim wording from the response “Providers of healthcare services are responsible for the quality and safety of the care they provide. I expect the healthcare providers at HMP Lewes to look into the care provided to Mr Haines and to consider where improvements can be made. This includes how they work with the prison authorities and other relevant organisations, including NHS England which is responsible for commissioning healthcare services for prisoners. Given its role in monitoring, inspecting and regulating the providers of health and social care in prisons, my officials have brought your reports to the attention of the Care Quality Commission (CQC).” Source location 2019-0486-Response-by-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 Healthcare providers are responsible for the quality and safety of care, including investigating care and considering improvements.
Verbatim wording from the response “Providers of healthcare services are responsible for the quality and safety of the care they provide. I expect the healthcare providers at HMP Lewes to look into the care provided to Mr Haines and to consider where improvements can be made. This includes how they work with the prison authorities and other relevant organisations, including NHS England which is responsible for commissioning healthcare services for prisoners. Given its role in monitoring, inspecting and regulating the providers of health and social care in prisons, my officials have brought your reports to the attention of the Care Quality Commission (CQC).” Source location 2019-0486-Response-by-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 National Prison Healthcare Board is responsible for overseeing and managing the partnership agreement and delivering its shared objectives.
Verbatim wording from the response “The National Prison Healthcare Board has responsibility for the oversight and on-going management of the Agreement and delivery of the shared objectives.” Source location 2019-0486-Response-by-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