25 Oct 2016 Ivy Atkin · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 2 Lack of reliable independent and objective assessment of Nominated Individual suitability View source Failure to obtain and consider DBS certificates for proposed Nominated Individuals View source
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AI-generated summary
Ivy Atkin · 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
Ivy Atkin was a resident at Autumn Grange Residential Care Home and died as a result of gross neglect. The Provider and its Nominated Individual were convicted of offences arising directly from her death, and an inquest recorded a conclusion of unlawful killing. Concerns included the Nominated Individual’s failure to provide a DBS certificate and a regulatory loophole affecting the independent assessment of suitability for that role.
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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 reliable independent and objective assessment of Nominated Individual suitability
Wider context from the report “1. ████████ had criminal convictions including for an offence involving violence against another person. He had not provided a Disclosure and Barring Service (“DBS”) certificate to the CQC nor been asked to do so, before becoming Nominated Individual.
2. The CQC were therefore unable to assess whether or not ████████ was of good character and was suitable for the position of Nominated Individual, that person being responsible for the supervising the management of a Residential Care Home, a role which ████████ undertook.
3. This is because the CQC expected and still expects a Provider to consider DBS certificates and make decisions as to the suitability of a proposed Nominated Individual, where the Provider is (as was here) a limited company.
4. In the case of a small family owned limited company, where the controlling director and Nominated Individual are one and the same person, as in this case, there is therefore no reliable nor independent nor objective means of assessing the good character, safety and suitability of a Nominated Individual.
5. This is because the wording of the present Regulation 6 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 allows for such a “loophole”, and/or in the alternative the manner in which the CQC interprets its powers and duties in the light of this Regulation allows for such a loophole.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 and consider DBS certificates for proposed Nominated Individuals
Wider context from the report “1. ████████ had criminal convictions including for an offence involving violence against another person. He had not provided a Disclosure and Barring Service (“DBS”) certificate to the CQC nor been asked to do so, before becoming Nominated Individual.
2. The CQC were therefore unable to assess whether or not ████████ was of good character and was suitable for the position of Nominated Individual, that person being responsible for the supervising the management of a Residential Care Home, a role which ████████ undertook.
3. This is because the CQC expected and still expects a Provider to consider DBS certificates and make decisions as to the suitability of a proposed Nominated Individual , where the Provider is (as was here) a limited company.
4. In the case of a small family owned limited company, where the controlling director and Nominated Individual are one and the same person, as in this case, there is therefore no reliable nor independent nor objective means of assessing the good character, safety and suitability of a Nominated Individual.
5. This is because the wording of the present Regulation 6 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 allows for such a “loophole”, and/or in the alternative the manner in which the CQC interprets its powers and duties in the light of this Regulation allows for such a loophole.
” 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 Providers remain responsible for managing and delivering care; CQC should not oversee providers’ management decisions.
Verbatim wording from the response “The underpinning principle of the regulatory regime in health and social care is that providers remain responsible for the management and delivery of the care that they offer. The role of the CQC is to assess providers to give assurance that they are taking the necessary steps to fulfil their legal duties and, where appropriate, to take regulatory enforcement action if providers are failing in their duty. In the view of the Department of Health, it would be neither desirable nor practical for the CQC to take on a role in which it was overseeing the management decisions of providers. For this reason, the legislation is established in a way that requires providers to demonstrate to the CQC that they have appropriate systems and processes in place to manage and oversee the care that they provide.” Source location 2016-0379-Response-by-Department-of-Health
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing Fit and Proper Persons Requirements provide CQC with sufficient powers to oversee providers’ appointment of directors.
Verbatim wording from the response “CQC’s response to your letter also details changes to the legislation that have come into place since 2012 relating to the Fit and Proper Persons Requirements (Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). These regulations require that a provider must check that an individual is of good character, with the necessary skills and qualifications and has not been involved in previous misconduct or mismanagement before they can be appointed as a director of a provider. This regulation places wide duties of diligence on providers, and the CQC’s role will be to ensure that providers have proper systems and processes in place to undertake these assessments. If the CQC has concerns about the process of decisions that a provider is taking when appointing directors, it can use its regulatory powers.” Source location 2016-0379-Response-by-Department-of-Health
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing nominated-individual arrangements and CQC’s general powers provide proportionate assurance, so the system should be maintained.
Verbatim wording from the response “You raise concerns around the role of the nominated individual, particularly the fact that CQC does not check DBS records for individuals fulfilling this role. The role of the nominated individual is essentially that of a point of contact between the care provider and the CQC for the purposes of correspondence and other regulatory business. For this reason, the nominated individual is not registered directly with the CQC. This is different in the case of Registered Managers, who are legally responsible for the care being delivered within care organisations; these individuals are registered directly with the CQC, and therefore vetted more closely by CQC upon registration.” Source location 2016-0379-Response-by-Department-of-Health
Open published response
Concerns raised 7 Failure to identify the roles and responsibilities of involved health and social care professionals View source Lack of a local community support network for patients diagnosed with personality disorder View source Failure to review patients after 2 admissions within 6 months View source Lack of local psychiatric intensive care unit beds for female patients View source Lack of effective community psychiatric nurse involvement View source Failure to adhere to the care programme approach View source Unavailability of community support for patients with challenging presentations 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
Victoria Georgia Halliday · 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
Victoria Georgia Halliday’s mental health deteriorated in 2015, with repeated crises, missing-person incidents, suspected psychotic symptoms and discharge back into the community. She was discovered to have taken her own life after a final missing-person search commenced on 29 July. Concerns included inadequate community psychiatric support, lack of local intensive psychiatric beds for female patients, failures in care planning and guideline adherence, and insufficient support networks for people diagnosed with personality disorder.
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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 identify the roles and responsibilities of involved health and social care professionals
Wider context from the report “4) The care programme approach (CPA) was not adhered to and NICE guidelines were not followed, specifically in ensuring there was a review after 2 admissions within 6 months, and to ensure the roles and responsibilities of all health and social care professionals involved were identified .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 local community support network for patients diagnosed with personality disorder
Wider context from the report “5) There is no local network for the community support of patients diagnosed with personality disorder , although evidence suggested such networks were effective when adopted elsewhere.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to review patients after 2 admissions within 6 months
Wider context from the report “4) The care programme approach (CPA) was not adhered to and NICE guidelines were not followed, specifically in ensuring there was a review after 2 admissions within 6 months , and to ensure the roles and responsibilities of all health and social care professionals involved were identified.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 local psychiatric intensive care unit beds for female patients
Wider context from the report “1) There are currently no local psychiatric intensive care unit beds for female patients and this means all female patients can only be placed out of area, potentially many miles away from home and local 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 Lack of effective community psychiatric nurse involvement
Wider context from the report “2) There was no, or no effective, community psychiatric nurse involvement and this was a missed opportunity to monitor and assist Victoria when she was 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 adhere to the care programme approach
Wider context from the report “4) The care programme approach (CPA) was not adhered to and NICE guidelines were not followed, specifically in ensuring there was a review after 2 admissions within 6 months, and to ensure the roles and responsibilities of all health and social care professionals involved were identified.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 community support for patients with challenging presentations
Wider context from the report “3) The “community support” referred to by the in-patient clinicians does not exist in reality for patients with this challenging presentation , leaving discharged patients and their families without adequate support.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £400 million of additional investment through 2020/21 to improve community mental health provision.
Verbatim wording from the response “The Government announced an additional £400m investment up to 2020/21 to improve the quality of community mental health provision as an effective and safe alternative to hospital admission. This builds on the successful National Mental Health Crisis Care Concordat which has seen every local area develop a crisis care action plan to ensure that no-one in crisis is turned away.” Source location 2016-0370-Response-by-Department-of-Health
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement comprehensive community-based mental health pathways so people access care at the right time and place.
Verbatim wording from the response “We want to eliminate unnecessary out of area placements for adult acute mental health care by 2020/21 and reduce significantly delayed transfers of care so that people can move from hospital to care in the community, ensuring that beds are available for those most in need. We appreciate that this will not happen overnight but we are committed to delivering change. Also, through the Five Year Forward View, we will implement a comprehensive set of community-based mental health pathways of care so that people have access to care at the right time in the right place.” Source location 2016-0370-Response-by-Department-of-Health
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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 revised Mental Health Act Code of Practice strengthening patient rights and involvement of families, carers and friends.
Verbatim wording from the response “You have raised concerns about the quality of care planning in Victoria Halliday’s case. We published a revised Mental Health Act 1983 Code of Practice in 2015 which strengthened the guiding principles of the Code. This included strengthening the rights of patients and better involvement of patients’ family, carers and friend in their care so that they can provide the much needed support for patients to manage their condition and support recovery and independent living in the community.” Source location 2016-0370-Response-by-Department-of-Health
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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 clinical commissioning groups are responsible for commissioning psychiatric intensive care beds because they assess and meet local community needs.
Verbatim wording from the response “You have raised concerns about the availability of psychiatric intensive care beds locally for women. Psychiatric intensive care beds are commissioned locally by clinical commissioning groups (CCGs) as they are best placed to assess and meet the needs of their local communities.” Source location 2016-0370-Response-by-Department-of-Health
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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 mental health commissioners and providers are responsible for taking necessary action when care-planning shortfalls are identified.
Verbatim wording from the response “You have raised concerns about the quality of care planning in Victoria Halliday’s case. We published a revised Mental Health Act 1983 Code of Practice in 2015 which strengthened the guiding principles of the Code. This included strengthening the rights of patients and better involvement of patients’ family, carers and friend in their care so that they can provide the much needed support for patients to manage their condition and support recovery and independent living in the community.” Source location 2016-0370-Response-by-Department-of-Health
Open published response
Concerns raised 11 Delays and lack of clarity in prescribing deterioration monitoring View source Delays in Heparin-level testing and result availability View source Lack of clarity in recording whether Alteplase was followed by an infusion View source Unsafe use of unfractionated Heparin View source Clerking of acute patients by a medical student View source Failure to consider full-leg scanning for suspected lower-leg DVT View source Inappropriate placement of Emergency Department patients in AMU View source Poor safety-netting after attendance and scanning View source Poor recording of medication delivery View source Inconsistent practice regarding lower-leg scanning for deep vein thrombosis View source Delays in medical assessment of patients with classical DVT/PE symptoms View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Captain James Michael Bedford · 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
Captain James Michael Bedford, a senior long-haul airline pilot, developed a left-leg deep vein thrombosis and later collapsed after a flight from China. He suffered a pulmonary embolus and cerebral events, followed by an acute cerebral haemorrhage after treatment with heparin, and died on 30 June 2015. Concerns included differing hospital practices regarding lower-leg scanning for DVT and whether a full-leg scan at his first attendance might have provided an opportunity for treatment.
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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 and lack of clarity in prescribing deterioration monitoring
Wider context from the report “3. Whilst it is accepted that Emergency Departments are often busy, and sometimes exceptionally so, there was criticism at the inquest of the priority given to Captain Bedforth on his second admission when he was displaying classical symptoms of a DVT/PE. It appears that he was not medically assessed for at least two and a half hours after admission by ambulance. Deterioration was not prescribed until three hours post-admission and there was no evidence as to exactly when it was given (although likely shortly thereafter).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Heparin-level testing and result availability
Wider context from the report “5. There was no criticism of the use of 50mg Alteplase but there was a lack of clarity as to whether this was followed by an infusion. A further expert witness (a haematologist) criticised the subsequent use of unfractionated Heparin and a test of Heparin level seems to have taken a long time from sampling to delivery to the laboratory and later result . The evidence was strongly suggestive of over-anticoagulation by Heparin.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in recording whether Alteplase was followed by an infusion
Wider context from the report “5. There was no criticism of the use of 50mg Alteplase but there was a lack of clarity as to whether this was followed by an infusion . A further expert witness (a haematologist) criticised the subsequent use of unfractionated Heparin and a test of Heparin level seems to have taken a long time from sampling to delivery to the laboratory and later result. The evidence was strongly suggestive of over-anticoagulation by Heparin.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 use of unfractionated Heparin
Wider context from the report “5. There was no criticism of the use of 50mg Alteplase but there was a lack of clarity as to whether this was followed by an infusion. A further expert witness (a haematologist) criticised the subsequent use of unfractionated Heparin and a test of Heparin level seems to have taken a long time from sampling to delivery to the laboratory and later result. The evidence was strongly suggestive of over-anticoagulation by Heparin .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Clerking of acute patients by a medical student
Wider context from the report “4. An expert witness (an ED physician) was critical of the placement in AMU and clerking in by a medical student although it is not suggested this of itself made a difference as to survival.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to consider full-leg scanning for suspected lower-leg DVT
Wider context from the report “1. The inquest heard that the scanning practice followed after the first attendance was in accordance with NICE guidelines (indeed possibly a little in excess of the guidance) which did not include scanning of the lower leg . This was said to be on the basis that not all lower leg DVTs will be visible. Yet it became apparent that that there is mixed practice on this point, some hospitals clearly consider that lower leg scanning is worthwhile .
Hindsight strongly suggested that Captain Bedforth was developing clots in the left lower leg at the time of the first visit. The inquest found that a full leg scan might have provided the hospital with an opportunity to treat Captain Bedforth although it was accepted that no-one could be certain of this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inappropriate placement of Emergency Department patients in AMU
Wider context from the report “4. An expert witness (an ED physician) was critical of the placement in AMU and clerking in by a medical student although it is not suggested this of itself made a difference as to survival.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor safety-netting after attendance and scanning
Wider context from the report “2. The evidence of 'safety-netting' after the first attendance (and/or subsequent attendance for scans) was poor and of considerable concern . As made clear in my written findings this was possibly of relevant as to Captain Bedforth's subsequent decision on seeking medical attention in or upon return from China.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor recording of medication delivery
Wider context from the report “6. A number of issues were raised as to note-keeping or clarity of note-keeping, most particularly as regards delivery of medications .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 practice regarding lower-leg scanning for deep vein thrombosis
Wider context from the report “The inquest heard that the scanning practice followed after the first attendance was in accordance with NICE guidelines (indeed possibly a little in excess of the guidance) which did not include scanning of the lower leg . This was said to be on the basis that not all lower leg DVTs will be visible. Yet it became apparent that there is mixed practice on this point, some hospitals clearly consider that lower leg scanning is worthwhile .
Hindsight strongly suggested that Captain Bedford was developing clots in the left lower leg at the time of the first visit. The inquest found that a full leg scan might have provided the hospital with an opportunity to treat Captain Bedford although it was accepted that no-one could be certain of this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in medical assessment of patients with classical DVT/PE symptoms
Wider context from the report “3. Whilst it is accepted that Emergency Departments are often busy, and sometimes exceptionally so, there was criticism at the inquest of the priority given to Captain Bedforth on his second admission when he was displaying classical symptoms of a DVT/PE. It appears that he was not medically assessed for at least two and a half hours after admission by ambulance . Deterioration was not prescribed until three hours post-admission and there was no evidence as to exactly when it was given (although likely shortly thereafter).
” 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 Evidence does not establish that lower-leg scanning would have changed treatment, because benefits of treating isolated distal DVT remain unclear.
Verbatim wording from the response “However, RSMVF also points out that the evidence for treating distal DVT alone is weak and cites a recent CACTUS trial (lancet haematology 2016) which showed no benefit in treating symptomatic below knee DVT. RSMVF is of the opinion that even if Captain Bedforth had had a full leg scan, and had been found to have a below knee DVT in April 2015, the evidence is not clear on whether he should have been immediately anticoagulated at that time.” Source location 2016-0368-Response-by-Department-of-Health
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NICE is responsible for considering and responding on whether lower-leg scanning should be included in relevant clinical guidance.
Verbatim wording from the response “The inquest heard that the scanning practice followed after Captain Bedforth’s first attendance in April 2015, was in accordance with NICE guidelines which do not include scanning the lower leg. As it became apparent there is mixed clinical practice on this point, your view is that some hospitals consider that lower leg scanning is worthwhile. As most hospitals are, or should be, working to NICE guidelines, I therefore advised that you should consider inviting NICE to respond to this case directly. My officials provided you with contact details and I understand that NICE are looking into this and will respond directly to you and copy me into their reply. I have also consulted the Royal Society of Medicine Venous Forum (RSMVF) and asked for their comments on this case.” Source location 2016-0368-Response-by-Department-of-Health
Open published response
Concerns raised 4 Failure to train care staff in basic emergency call processes View source Lack of objectively assessed basic training and competence standards for HCAs View source Failure to train care staff in CPR and choking procedures View source Failure to highlight essential patient information during transfers between care homes View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Robert Arthur Davidson · 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
Robert Arthur Davidson, who had dementia, Alzheimer’s disease and PICA, died after choking on a plastic glove at a care home on 27 January 2016. The report identified concerns about inadequate transfer of information about his PICA, insufficient staff training and failures in emergency procedures, including calling emergency services and initiating CPR.
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 train care staff in basic emergency call processes
Wider context from the report “1. During the inquest I heard evidence that Health care staff had not been trained on basic process as follows:
• Making 999 calls – to obtain an outside line caller’s needed to first dial “9”. The HCA instructed to make the 999 call did not know this so the call was unsuccessful. The registered nurse looking after the patient whilst he was choking had to make the 999 call resulting in her leaving the patient.
• When to Start CPR. The RGN and HCA (Health Care Assistants) staff had received no training on the CPR and choking policy
The concern is that staff are not trained in basic processes and therefore not able to deal with emergency situations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 objectively assessed basic training and competence standards for HCAs
Wider context from the report “2. The two HCA’s had no experience or basic training before starting work as HCA’s. They had limited understanding of conditions and processes. Consideration needs to be given as to whether there should be mandatory training or minimum standards, which are objectively assessed, to ensure HCA’s have the necessary knowledge and understanding to undertake their role.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to train care staff in CPR and choking procedures
Wider context from the report “1. During the inquest I heard evidence that Health care staff had not been trained on basic process as follows:
• Making 999 calls – to obtain an outside line caller’s needed to first dial “9”. The HCA instructed to make the 999 call did not know this so the call was unsuccessful. The registered nurse looking after the patient whilst he was choking had to make the 999 call resulting in her leaving the patient.
• When to Start CPR. The RGN and HCA (Health Care Assistants) staff had received no training on the CPR and choking policy
The concern is that staff are not trained in basic processes and therefore not able to deal with emergency situations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 highlight essential patient information during transfers between care homes
Wider context from the report “3. The deceased PICA behaviour was not highlighted or identified on his transfer between care homes. Some process or direction from the governing body needs to be provided to care homes to ensure essential information is provided and highlighted when patients are transferred.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with Skills for Care to improve adult social care workforce skills.
Verbatim wording from the response “The Department is also continuing to work closely with our delivery partner, Skills for Care, a partner in the sector skills council for social care, to improve the level of skills of the adult social care workforce.” Source location 2016-0363-Response-by-Department-of-Health
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £12 million through the Workforce Development Fund to support adult social care employers with workforce training and qualifications.
Verbatim wording from the response “The Department is providing significant levels of funding to support training and development for the care workforce. In 2016/17, DH will invest £12m through the Workforce Development Fund which provides support to employers on modules and qualifications for their workers in adult services in the private and voluntary sectors.” Source location 2016-0363-Response-by-Department-of-Health
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 Maintain the Care Certificate as an induction and development standard covering safe, effective care for health and social care workers.
Verbatim wording from the response “In April 2015, the Government introduced the Care Certificate (as recommended by Camilla Cavendish in her July 2013 review), which is helping to ensure that support workers and their employers can deliver a consistently high quality standard of safe, effective and compassionate care. It includes 15 standards and outcomes that health and social care workers – in hospitals, care homes and people’s own homes – should know and be able to deliver in their daily work. Regarded as ‘best practice’ for the induction of new health and care assistants, it is also offering existing staff an opportunity to refresh or improve their knowledge.” Source location 2016-0363-Response-by-Department-of-Health
Open published response
3 Oct 2016 Amy El-Keria · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 5 Failure to assess and provide support for family contact when children are placed far from home View source Inadequate staffing levels for one-to-one care in inpatient CAMHS units View source Shortage of acute mental health beds near young people's homes View source Failure to maintain an ongoing welfare-support role for children placed at external facilities View source Lack of national staffing guidance for inpatient CAMHS units View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Amy El-Keria · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Amy El-Keria, aged 14, died on 13 November 2012 after tying a ligature around her neck and suspending herself from a radiator while receiving inpatient mental health care. The inquest identified concerns about staffing levels being insufficient to provide the one-to-one support in her care plan and the shortage of acute mental health beds for young people close to home, limiting family support.
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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 assess and provide support for family contact when children are placed far from home
Wider context from the report “(2) Social Services clearly have a vital role to play in ensuring family contact where a child is placed far from their family home where difficulties arise. There was no assessment carried out to assess whether there was any need to provide support to a child in need under Section 17 Children Act 1989 even when Amy’s mother had specifically raised the difficulties she was having with contact with Amy, including the cost of travel, with her support worker .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate staffing levels for one-to-one care in inpatient CAMHS units
Wider context from the report “(1) The Jury in this Inquest found that the staffing levels, which were in line with the ONIC staffing ratio, were inadequate to give Amy sufficient one to one time in accordance with her care plan . It is understood that in December 2014 the Department of Health tasked NICE with developing guidance on staffing levels for inpatient CAMHS units but this appears to have been discontinued. There is currently no national guidance on staffing levels for inpatient CAHMS
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 acute mental health beds near young people's homes
Wider context from the report “(2) There continues to be a shortage of acute mental health beds for young people close to where they live . This means that families have to travel long distances to visit their child and they are unable to provide the necessary day to day support to their child. Family support can play a very significant role in managing risk of suicide by avoiding and mitigating 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 Failure to maintain an ongoing welfare-support role for children placed at external facilities
Wider context from the report “(1) The evidence given at the Inquest showed that there was a clear misapprehension by Hounslow Social Services as to their role in supporting Amy whilst at Ticehurst . It appears that Social services did not appreciate their important ongoing role to ensure Amy’s welfare whilst placed at Ticehurst████████ the Court expert, gave evidence that Hounslow may have seen this as a health funded placement as a stand-alone intervention that did not require their input.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national staffing guidance for inpatient CAMHS units
Wider context from the report “(1) The Jury in this Inquest found that the staffing levels, which were in line with the ONIC staffing ratio, were inadequate to give Amy sufficient one to one time in accordance with her care plan. It is understood that in December 2014 the Department of Health tasked NICE with developing guidance on staffing levels for inpatient CAMHS units but this appears to have been discontinued . There is currently no national guidance on staffing levels for inpatient CAHMS
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop comprehensive community-based mental health service pathways and standards to support treatment closer to home.
Verbatim wording from the response “However, we should also be seeking to avoid unnecessary admissions to hospital wherever possible. That is why the Government is developing a comprehensive set of community-based mental health service pathways and standards so that more people can be treated in the community closer to home. We have also invested £400 million to improve crisis care services in the community so that people receive the right care” Source location 2016-0347-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £400 million to improve community crisis-care services.
Verbatim wording from the response “However, we should also be seeking to avoid unnecessary admissions to hospital wherever possible. That is why the Government is developing a comprehensive set of community-based mental health service pathways and standards so that more people can be treated in the community closer to home. We have also invested £400 million to improve crisis care services in the community so that people receive the right care” Source location 2016-0347-Response-by-Department-of-Health
Open published response
Concerns raised 1 Failure to book follow-up appointments for discharged patients 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
Roy Gordon Millar · 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
Roy Gordon Millar attended hospital with slurred speech and facial droop, and scans identified an abnormality requiring follow-up. The repeat scan results were not sent to the correct consultant, and a requested outpatient appointment was not arranged. A brain tumour was identified after he re-presented with a more severe facial droop, but he died on the date planned for biopsy and debulking surgery; the report also describes failures to book follow-up appointments affecting approximately 146 patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to book follow-up appointments for discharged patients
Wider context from the report “PHNT instigated a Root Cause Analysis following this incident, a copy of which is enclosed. ████████ the author of the Report and the Trust’s Patient Safety Lead, attended the Inquest. During the course of the hearing it emerged that the Ward Administrat or in the Neurology Department had been recently appointed. She had been trained by her predecessor. Neither the previous nor the current Ward Administrator were aware of their responsibility to book follow-up appointments for patients who had been discharged. Their understanding was that appointments would be arranged by Consultants’ secretaries and it seems apparent that a large number of appointments were made in this way.
It emerged during the course of the Inquest that the Ward Administrators in the Neurology Department had not booked follow-up appointments for approximately 26 months. As you will see from the enclosed Root Cause Analysis, PHNT has reviewed 1000 patient admissions and it has revealed that 146 patients die not have follow-up appointments booked .
In Mr Millar’s case the evidence I heard was that the follow-up scan being conducted in June 2015 was likely to have led to a biopsy which would have diagnosed the brain tumour. If Mr Millar had undergone earlier surgery, the Inquest heard that he would have had a 50% chance of surviving for a year.
” Open source report
13 Sep 2016 Keith William Rushton · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 2 Inadequacy of ambulance response times View source Failure of telephone operator protocols to require comprehensive enquiries about long lays, particularly for obese patients 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
Keith William Rushton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Keith William Rushton slid from his bed at home on 15 December 2015 and was unable to get up, remaining there until he was found on 16 December. An ambulance arrived approximately two hours after it was called, and he died later that day from multi-organ failure and rhabdomyolysis associated with crush injuries to his legs. The concerns focused on ambulance response times and telephone protocols for identifying prolonged lies, particularly involving obese patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of ambulance response times
Wider context from the report “• To review and reconsider the adequacy of the existing response times given the two hour delay in responding to Mr Rushton.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 telephone operator protocols to require comprehensive enquiries about long lays, particularly for obese patients
Wider context from the report “• To review existing protocols governing the allocation of information by telephone operators to incorporate more comprehensive enquiries with respect to long lays, particularly in the case of obese patients , in order to ensure adequate delivery of appropriate ambulance response times.
” Open source report
Concerns raised 1 Failure of safeguarding systems to prevent risks posed by residents to other residents 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
Arthur Thomas Adley · 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
Arthur Thomas Adley, a resident at Candle Court Nursing Home, was pushed by another resident on 8 April 2016, fell and struck his face and head on a table, and died in hospital the same day. The substantive concern was that safeguarding systems did not prevent risks posed to other residents by residents who presented a risk when placed in care homes.
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 safeguarding systems to prevent risks posed by residents to other residents in care homes
Wider context from the report “That the systems for safeguarding for residents who present a risk to other residents when placed in care homes did not prevent that risk to other residents .
” 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 Oversight of the reported safety concerns was assigned to the Care Quality Commission as the independent regulator of providers.
Verbatim wording from the response “The CQC is the independent regulator of health and adult social care providers in England. I have, therefore, sent your report to the Care Quality Commission (CQC) as the body with oversight in the case.” Source location 2016-0358-Response-by-Department-of-Health
Open published response
Concerns raised 6 Inadequate staff training on responsibility for patient contact View source Failure to ensure staff-led contact for patients with severe mental health conditions View source Lack of adequate post-discharge mental health care and contact View source Failure of effective and robust duty system arrangements View source Failure of an effective and robust buddying system View source Unavailability of female psychiatric intensive care beds in Devon 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
Louise Turner · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Louise Turner died on 27 June 2014 from inhalation of helium after recently being discharged from a lengthy inpatient stay while receiving treatment for a serious mental health illness. The report raised concerns about inadequate post-discharge care and contact, ineffective duty and buddying arrangements, expectations that patients initiate contact, and the absence of female intensive psychiatric care beds in Devon.
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 staff training on responsibility for patient contact
Wider context from the report “(3) There was a suggestion at Inquest that the patients themselves were expected to be in charge of making contact. In cases of severe mental health, this does not appear to be appropriate or realistic, and the Devon Partnership Trust should reconsider this and/or the training of their staff who hold this belief .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 staff-led contact for patients with severe mental health conditions
Wider context from the report “(3) There was a suggestion at Inquest that the patients themselves were expected to be in charge of making contact . In cases of severe mental health, this does not appear to be appropriate or realistic , and the Devon Partnership Trust should reconsider this and/or the training of their staff who hold this belief.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 adequate post-discharge mental health care and contact
Wider context from the report “(1) The Devon Partnership trust had no adequate mental health care for Louise after she was discharged . There was inadequate contact and no explanation at Inquest as to why this had not taken place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of effective and robust duty system arrangements
Wider context from the report “(2) The duty system arrangements and buddying system referred to at Inquest were not effective or robust and need to be reconsidered in the light of the outcome of this case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of an effective and robust buddying system
Wider context from the report “(2) The duty system arrangements and buddying system referred to at Inquest were not effective or robust and need to be reconsidered in the light of the outcome of this case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of female psychiatric intensive care beds in Devon
Wider context from the report “(4) There are no female intensive care beds for psychiatric patients in Devon . This does not match the desired parity of mental health care with physical health care. Devon Partnership Trust needs to consider future planning and provision to ensure the needs of patients can be met.
” Open source report
Concerns raised 2 Failure to incorporate the significance of head injury in patients undergoing haemodialysis or with significant uraemia due to renal failure into relevant NICE guidelines View source Lack of awareness within the medical profession of haemorrhage risk after head injury in patients undergoing haemodialysis or with significant uraemia due to renal failure 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
Dildar Shariff · 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
Dildar Shariff died at Fairfield General Hospital on 10 May 2016 after a cardiac arrest, following a fall, head pain and vomiting. An intracerebral haemorrhage was confirmed, and the report states that his haemodialysis placed him at increased risk of haemorrhage. The principal concern was that this risk was not widely recognised or referred to in the relevant NICE guidelines, potentially creating a risk to other patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate the significance of head injury in patients undergoing haemodialysis or with significant uraemia due to renal failure into relevant NICE guidelines
Wider context from the report “Evidence was given that patients who are undergoing haemodialysis or with significant uraemia due to renal failure, such as Mr Shariff, are at increased risk of a haemorrhage and that this is not commonly known within the medical profession or referred to in the relevant NICE guidelines. This lack of awareness could create a risk that other deaths will continue to exist or occur in the future and whilst I am satisfied that the Trust have taken this matter very seriously, in that they have implemented appropriate measures to reduce the risk of this occurring in the future, I am concerned with the National procedures as I am mindful that it may take some time for the significance of a head injury within patients with undergoing haemodialysis or with significant uraemia due to renal failure to be incorporated into the NICE guidelines .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness within the medical profession of haemorrhage risk after head injury in patients undergoing haemodialysis or with significant uraemia due to renal failure
Wider context from the report “Evidence was given that patients who are undergoing haemodialysis or with significant uraemia due to renal failure, such as Mr Shariff, are at increased risk of a haemorrhage and that this is not commonly known within the medical profession or referred to in the relevant NICE guidelines. This lack of awareness could create a risk that other deaths will continue to exist or occur in the future and whilst I am satisfied that the Trust have taken this matter very seriously, in that they have implemented appropriate measures to reduce the risk of this occurring in the future, I am concerned with the National procedures as I am mindful that it may take some time for the significance of a head injury within patients with undergoing haemodialysis or with significant uraemia due to renal failure to be incorporated into the NICE guidelines.
” Open source report
23 Aug 2016 MICHAEL DUNDON · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1 Lack of staff awareness of the ingestion hazards of liquid-absorbing crystals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
MICHAEL DUNDON · 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
Michael Dundon died after ingesting safety gel liquid-absorbing crystals that had been placed in unused urine bottles in his hospital room. He was unsupervised despite needing one-to-one supervision, and the crystals caused an airway blockage and cardiorespiratory arrest. The principal concerns were that the risks of the crystals were not fully understood and that staff needed awareness, training, and risk assessments regarding their safe use.
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 staff awareness of the ingestion hazards of liquid-absorbing crystals
Wider context from the report “(3) The crystals had been pre-inserted into two empty urine bottles in the deceased’s room. The staff did not recognise that such sachets could be hazardous when left in this way. The deceased was able, whilst unsupervised, to swallow crystals, causing a cardiorespiratory arrest and death.
(4) The risks associated with the use of these crystals may not be fully understood.
” 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 Liaise with the Care Quality Commission to distribute resulting advice or guidance to care homes and hospices.
Verbatim wording from the response “Once NHS Improvement has identified the most effective way of managing the choking hazard while ensuring infection control benefits can be maintained, it intends to notify providers of NHS-funded care. NHS Improvement will liaise with the Care Quality Commission to ensure that any advice or guidance is also distributed to care homes and hospices.” Source location 2016-0305-Response-by-Department-of-Health
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 Consider warning staff about the choking risk and the need for risk assessment.
Verbatim wording from the response “This work will include consideration of a warning to staff of the risk presented and the need for risk assessment as you recommend. However, I am advised that initial considerations by NHS Improvement are that any such warning would have a limited effect, as a high proportion of hospital inpatients have some degree of cognitive or visual impairment, and confused patients might typically pick up urine bottles or other receptacles from other patients.
NHS Improvement has further advised that any blanket restriction on their use potentially also risks patient harm through making handling and disposal of bodily fluids more difficult, with an impact on infection control procedures, as well as affecting patient comfort and dignity.” Source location 2016-0305-Response-by-Department-of-Health
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 Notify providers of NHS-funded care once the most effective choking-hazard controls are identified.
Verbatim wording from the response “Once NHS Improvement has identified the most effective way of managing the choking hazard while ensuring infection control benefits can be maintained, it intends to notify providers of NHS-funded care. NHS Improvement will liaise with the Care Quality Commission to ensure that any advice or guidance is also distributed to care homes and hospices.” Source location 2016-0305-Response-by-Department-of-Health
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 Patient safety leadership and the response to this concern lie with NHS Improvement rather than the Department of Health.
Verbatim wording from the response “The Department has liaised with a number of agencies to ascertain where responsibility lies for determining the most appropriate response to your concerns.” Source location 2016-0305-Response-by-Department-of-Health
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 A warning may have limited effect, while a blanket restriction could cause patient harm and undermine infection control, comfort and dignity.
Verbatim wording from the response “This work will include consideration of a warning to staff of the risk presented and the need for risk assessment as you recommend. However, I am advised that initial considerations by NHS Improvement are that any such warning would have a limited effect, as a high proportion of hospital inpatients have some degree of cognitive or visual impairment, and confused patients might typically pick up urine bottles or other receptacles from other patients.
NHS Improvement has further advised that any blanket restriction on their use potentially also risks patient harm through making handling and disposal of bodily fluids more difficult, with an impact on infection control procedures, as well as affecting patient comfort and dignity.” Source location 2016-0305-Response-by-Department-of-Health
Open published response
Concerns raised 2 Lack of an audit trail for faxed referrals to the Community Mental Health Team View source Failure to consistently telephone the Community Mental Health Team to confirm receipt of faxed referrals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Miles Benedict Abel · 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 14 January 2016, Miles Benedict Abel died after placing a ligature around his neck while at home. The concerns related to the referral process from a GP surgery to the Community Mental Health Team, including the absence of an audit trail confirming that referral faxes were sent and inconsistent follow-up calls to check receipt.
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 an audit trail for faxed referrals to the Community Mental Health Team
Wider context from the report “(1)The procedure in place at the time of Miles death where a GP from the surgery wished to refer a patient to the Community Mental Health Team was to fax the request but no audit trail was kept to show the fax had been sent .
(2 ) Although a telephone call was supposed to be made by the surgery to check that the fax had been received this was not always followed.
(3) Hence if for any reason the fax was not sent and the follow up telephone call was not made the Community Mental Health Team would be unaware of the fact a patient had been referred to 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 Failure to consistently telephone the Community Mental Health Team to confirm receipt of faxed referrals
Wider context from the report “(1)The procedure in place at the time of Miles death where a GP from the surgery wished to refer a patient to the Community Mental Health Team was to fax the request but no audit trail was kept to show the fax had been sent.
(2 ) Although a telephone call was supposed to be made by the surgery to check that the fax had been received this was not always followed .
(3) Hence if for any reason the fax was not sent and the follow up telephone call was not made the Community Mental Health Team would be unaware of the fact a patient had been referred to them.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The strengthened and robust local referral system is considered sufficient to address referrals to the Community Mental Health Team.
Verbatim wording from the response “Your concern relates to the process followed at the Endless Street Surgery for referring patients to the Community Mental Health Team. I am aware that the Surgery has responded to your concerns, confirming that a strengthened and robust system for referral of patients to the Community Mental Health Team is now in place.” Source location 2016-0277-Response-by-Department-of-Health
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 Responsibility for addressing the referral process rests locally with the surgery rather than centrally.
Verbatim wording from the response “Your concern relates to the process followed at the Endless Street Surgery for referring patients to the Community Mental Health Team. I am aware that the Surgery has responded to your concerns, confirming that a strengthened and robust system for referral of patients to the Community Mental Health Team is now in place.” Source location 2016-0277-Response-by-Department-of-Health
Open published response
Concerns raised 4 Unavailability of acute mental health inpatient beds View source Limited resources and care for vulnerable people in the community View source Failure to control access to available medication for a person at risk of overdose View source Failure to undertake a formal suicide and overdose risk assessment 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
Patricia Ann Cleghorn · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Patricia Ann Cleghorn, who had suicidal ideation and was awaiting an inpatient mental health bed, was found collapsed at home after receiving diazepam and was declared dead by paramedics on 14 December 2015. The concerns were the lack of an available inpatient bed, allowing her to self-medicate with potentially dangerous drugs despite repeated statements that she intended to overdose, and the absence of a formal risk assessment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of acute mental health inpatient beds
Wider context from the report “(1) The deceased could not be admitted to hospital as there were no inpatient beds available . I heard evidence at the inquest that had she been admitted it is unlikely she would have died when she did. The availability of acute mental health beds means the most vulnerable people are being cared for in the community with limited resources and care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Limited resources and care for vulnerable people in the community
Wider context from the report “(1) The deceased could not be admitted to hospital as there were no inpatient beds available. I heard evidence at the inquest that had she been admitted it is unlikely she would have died when she did. The availability of acute mental health beds means the most vulnerable people are being cared for in the community with limited resources and care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to control access to available medication for a person at risk of overdose
Wider context from the report “(2) The deceased had repeatedly stated that she would end her life by taking an overdose. Despite this she was left at home self-medicating drugs including amitriptyline, MST and oromorph . No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a formal suicide and overdose risk assessment
Wider context from the report “(2) The deceased had repeatedly stated that she would end her life by taking an overdose. Despite this she was left at home self-medicating drugs including amitriptyline, MST and oromorph. No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her.
” 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 Set the expectation that beds must always be available for people who need them.
Verbatim wording from the response “The Government has made it clear that beds must always be available for those who need them.” Source location 2016-0270-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust is responsible for addressing concerns about medication access, risk assessment and staff recognition of available drugs.
Verbatim wording from the response “The second issue is one for the Trust to answer:” Source location 2016-0270-Response-by-Department-of-Health
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 Availability of acute mental health beds is a matter for local commissioners.
Verbatim wording from the response “The Crisis Care Concordat makes it clear that local commissioners should commission a range of mental health services that allow beds to be available for a person in urgent need. Each local area in England has produced its own ‘Mental Health Crisis Declaration’.” Source location 2016-0270-Response-by-Department-of-Health
Open published response
Concerns raised 1 Risk of death associated with the drain View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Kane · 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 Kane was admitted to hospital with gross ascites caused by advanced liver cirrhosis. A drain was inserted without an ultrasound scan on 2 January 2016, and after approximately 7.5 litres of fluid were drained, his condition deteriorated within an hour of the drain being removed; he died later on 3 January 2016. The principal concern was whether ultrasound scanning before drain insertion might have reduced the risk of bowel injury and death, despite there being no local support for changing existing policy or guidance.
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 Risk of death associated with the drain
Wider context from the report “Notwithstanding that a local discussion of the circumstances of this case has taken place and there having been no local support for a change in policy or guidance, given the evidence that the deceased would not have died when he did but for the drain and that it is possible that a scan may have reduced the risk of death I believe this is a matter that requires further thought and consideration.
” 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 NICE about whether guidance should recommend ultrasound before ascites drainage.
Verbatim wording from the response “You explained that Mr Kane suffered an injury to the bowel, which is a recognised but rare medical complication associated with paracentesis. You asked that we consider whether insertion of a drain should always be preceded by an ultrasound scan.” Source location 2016-0253-Response-by-Department-of-Health
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 Consult the Royal College of Radiologists about routine ultrasound before or during ascites drainage.
Verbatim wording from the response “In addition, the Department of Health also consulted the Royal College of Radiologists on the general issue as to whether ultrasound scanning should always be performed immediately prior to drainage of abdominal ascitic fluid. They, in turn, sought advice from the following:” Source location 2016-0253-Response-by-Department-of-Health
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 Highlight the ultrasound-scan concern to NICE’s guideline surveillance team for future guideline consideration.
Verbatim wording from the response “NICE do not believe the guideline needs to be amended at this time. However, your concerns have been highlighted to the guideline surveillance team, for their information when the guideline is next considered for an update.” Source location 2016-0253-Response-by-Department-of-Health
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 Routine ultrasound before or during paracentesis is not considered necessary because trained operators following established guidelines make the procedure safe.
Verbatim wording from the response “The Royal College of Radiologists does not consider there is a case for the routine use of ultrasound prior to or during paracentesis. It is the College’s view that paracentesis is a safe procedure when performed by trained, competent operators following established guidelines on the appropriate use of the procedure.” Source location 2016-0253-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The NICE cirrhosis guideline does not need amendment at this time; the concern will be considered during future surveillance.
Verbatim wording from the response “I have consulted the National Institute for Health and Care Clinical Excellence (NICE) on this matter and have been advised that their recently published guidance - Cirrhosis in over 16s: assessment and management (NG50) - does not make any specific recommendations as to whether or not a scan should be taken prior to the insertion of a drain for ascites. This guidance can be found at https://www.nice.org.uk/guidance/ng50. The issue was not raised by stakeholders during the NICE consultation on the guideline scope, nor by the scoping team, and it was therefore not addressed during the development of the guideline.” Source location 2016-0253-Response-by-Department-of-Health
Open published response
Concerns raised 14 Failure to act on early warning scores View source Failure to carry out maternal observations after delivery despite a temperature spike View source Failure to recognise signs and symptoms of neonatal deterioration View source Inadequate clinical communication and handover View source Inadequate preceptorship for newly qualified and part-time midwives View source Failure of midwives to escalate to or consult with relevant specialist clinicians View source Failure to carry out speculum examination to establish rupture of membranes View source Failure to document rationale for clinical discretion View source Failure to carry out neonatal observations after material change in condition View source Failure to routinely offer intrapartum prophylactic antibiotics to women with current or previous positive GBS tests View source Failure of staff to follow clinical protocols and guidance View source Failure to routinely offer antenatal GBS screening to pregnant women during the final weeks of pregnancy View source Miscalculation of early warning scores View source Inadequate clinical record keeping View source See 11 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
baby Dominic Smith · 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
Baby Dominic Smith was born on 2 June 2015 after a prolonged labour and died at approximately 18 hours of life following a collapse. The report describes pneumonia as the cause of death and identifies concerns including failure to recognise possible rupture of membranes and infection risk, inadequate maternal and neonatal observations, failure to escalate deterioration, delayed antibiotic treatment, and communication and record-keeping problems.
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 act on early warning scores
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon ;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 maternal observations after delivery despite a temperature spike
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature ;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 signs and symptoms of neonatal deterioration
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed ;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 clinical communication and handover
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 preceptorship for newly qualified and part-time midwives
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 midwives to escalate to or consult with relevant specialist clinicians
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 speculum examination to establish rupture of membranes
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes . The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 rationale for clinical discretion
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion ;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 neonatal observations after material change in condition
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition . Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 routinely offer intrapartum prophylactic antibiotics to women with current or previous positive GBS tests
Wider context from the report “Department of Health, NIHCE and the Royal Colleges:
1. I previously completed a PFD 13 month ago in relation to a neonatal GBS death. At that time I raised the following concerns:
- That antenatal screening for GBS was not being routinely offered by the NHS to all pregnant women during the final weeks of pregnancy,
- That prophylaxis intrapartum antibiotics were not routinely offered to all women who test positive for GBS (or have done so in the past)
&
- That given the seriousness of the illness, in the absence of a national screening and prophylactic treatment programme, babies were potentially being put at risk of harm/death.
During the course of the inquest into Baby Smith’s death the evidence suggested that no further action has been taken in this regard, despite the responses received in relation to the last PFD action.
I therefore raise the issues again as a concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to follow clinical protocols and guidance
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 routinely offer antenatal GBS screening to pregnant women during the final weeks of pregnancy
Wider context from the report “Department of Health, NIHCE and the Royal Colleges:
1. I previously completed a PFD 13 month ago in relation to a neonatal GBS death. At that time I raised the following concerns:
- That antenatal screening for GBS was not being routinely offered by the NHS to all pregnant women during the final weeks of pregnancy ,
- That prophylaxis intrapartum antibiotics were not routinely offered to all women who test positive for GBS (or have done so in the past)
&
- That given the seriousness of the illness, in the absence of a national screening and prophylactic treatment programme, babies were potentially being put at risk of harm/death.
During the course of the inquest into Baby Smith’s death the evidence suggested that no further action has been taken in this regard, despite the responses received in relation to the last PFD action.
I therefore raise the issues again as a concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Miscalculation of early warning scores
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated , ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 clinical record keeping
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping ;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report
Concerns raised 9 Failure to identify patients' previous contact with other healthcare agencies at the beginning of calls View source Failure to record conclusions and advice from earlier calls View source Failure of agencies to obtain information from previously involved agencies View source Absence of a lower threshold for recommending face-to-face medical review View source Remote diagnosis without face-to-face assessment View source Use of non-medically qualified personnel to select symptom questionnaires and care pathways View source Failure to peer review decisions to downgrade recommended advice outcomes View source Failure to establish whether patients have the means to attend advised emergency care View source Failure to review details of earlier calls when assessing subsequent calls 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
Kirsty Childs · 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
Kirsty Childs, aged 20, developed severe abdominal symptoms and repeatedly sought advice from NHS Direct and other services between 31 December 2012 and 2 January 2013. She was not admitted to hospital and was later found dead at home; the inquest recorded septic shock caused by an undiagnosed and untreated mesenteric venous thrombosis. The principal concerns included incorrect telephone triage, failure to review earlier calls, medically unqualified staff selecting questionnaires, the ability to override recommended outcomes, and poor information-sharing between agencies.
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 identify patients' previous contact with other healthcare agencies at the beginning of calls
Wider context from the report “1. There was no standard question asked at the beginning of the calls to identify whether the patient had previously contacted NHS Direct, or any other agency , with regard to the symptoms giving rise to the latest call.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to record conclusions and advice from earlier calls
Wider context from the report “5. It was not possible at the inquest to review what details were recorded. I was concerned that details of earlier calls may not contain the conclusion and advice given to the patient . This information may be of significant assistance to ensure that if the patient calls again, appropriate care and advice is given.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 obtain information from previously involved agencies
Wider context from the report “7. All the different agencies operated in isolation , and despite computerised systems and phone facilities being available, there was no attempt to gain information from previous agencies which they had been involved
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of a lower threshold for recommending face-to-face medical review
Wider context from the report “3. Nurse Advisers within NHS Direct were reaching a diagnosis in Kirsty's case, without having the opportunity to undertake a face to face assessment, and there did not appear to be a lower threshold of recommending a face to face medical review
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Remote diagnosis without face-to-face assessment
Wider context from the report “3. Nurse Advisers within NHS Direct were reaching a diagnosis in Kirsty's case, without having the opportunity to undertake a face to face assessment , and there did not appear to be a lower threshold of recommending a face to face medical review
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Use of non-medically qualified personnel to select symptom questionnaires and care pathways
Wider context from the report “2. Medical advisers in NHS Direct were not medically qualified, and emergency medical despatchers in West Yorkshire Ambulance service are not medically qualified. They were required to illicit details of the patient's symptoms, and proceed to identify the most significant symptom from the information gained to select the most appropriate questionnaire. I understand there are a significant number of questionnaires to select from. They repeatedly selected the incorrect questionnaire in Kirsty's case. This resulted in significantly different outcomes being followed. I am concerned that without medical training the likelihood of incorrect questionnaires being selected and as a consequence, incorrect pathways being followed will reoccur
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 peer review decisions to downgrade recommended advice outcomes
Wider context from the report “6. The Nurse Adviser was able to override the recommendation of the questionnaire programme to downgrade the recommended advice outcome. This led to a tragic outcome in Kirsty's case. If Kirsty had attended accident and emergency at an early stage rather than being diagnosed with a bug and to self- care, the evidence indicated she would have lived. There were no safeguards put in place for this decision to be peer reviewed if a decision is taken to downgrade the recommended advice outcome.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to establish whether patients have the means to attend advised emergency care
Wider context from the report “8. On the one occasion when NHS Direct advised Kirsty to attend her nearest accident and emergency service, no enquiry was made as to whether Kirsty had the means to attend .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to review details of earlier calls when assessing subsequent calls
Wider context from the report “4.Within NHS direct there was a complete consistency of treating each call separately, there was no attempt to review details of earlier calls made .
” Open source report
14 Jun 2016 Christina O'Brien · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1 Lack of non-hospital respite care options for mentally ill people in the community 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
Christina O'Brien · 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
Christina O'Brien died by suicide on 17 September 2015 after hanging herself outside her flat; she also had injuries to her arms and legs. She had a long-term mental illness and was receiving treatment and care from SLAM. The principal concern was that community respite options for people experiencing mental health crises were limited, particularly after the withdrawal of Dove House, a non-hospital respite facility that had previously benefited her.
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 non-hospital respite care options for mentally ill people in the community
Wider context from the report “(1) I am concerned that the options for mentally ill people in the community needing respite care through SLAM are limited solely to attendance by the Home Treatment team as the alternative to hospital admission . In this particular case I found that the availability of Dove House did, in the past, provide respite for the deceased. I also find, on the evidence I heard, that if this option had been available in 2015 the death might have been prevented. Whilst the Home Treatment team could provide support by way of medication and counselling it could not deal with the source of the distress the deceased was suffering from building work.
(2) Given the unpredictability of the perceptions of people with mental illness in the community I also found that having a further option of respite residence in a non hospital setting could prevent future self-inflicted deaths. Examples that spring to mind, in a high density area like Lambeth, might be bullying by neighbours or sources of excessive noise from neighbouring residences as well as building work.
(3) I am concerned the Dove House facility was withdrawn in about 2008 without any provision being made for alternative respite care when it appeared to have had a beneficial effect for the deceased and, by reasonable inference, other SLAM patients.
” Open source report
13 Jun 2016 Kevin Dermott · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 8 Failure to provide specialist hospital treatment for serious mental illness View source Inadequacies in mental health care planning and communication View source Inadequate mental health staffing and psychiatric referral provision View source Failure to recognise relapse into depression View source Failure to properly observe ACCT procedures View source Lack of suitable psychiatric care facilities View source Failure to plan ongoing mental health care and relapse management View source Failure to complete psychiatric referral and therapeutic medication care planning View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kevin Dermott · 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
Kevin Dermott, who had bipolar affective disorder and was serving a prison sentence, suffered episodes of mental illness while held at several prisons and died by hanging in his cell at HMP Risley on 19 May 2014. The concerns included inadequate mental health and psychiatric care, failures in care planning and communication, and failure to follow ACCT procedures; the jury concluded that deficiencies in mental health care and observation partly contributed to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide specialist hospital treatment for serious mental illness
Wider context from the report “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment . The evidence showed that his illness was not properly addressed . At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequacies in mental health care planning and communication
Wider context from the report “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison , the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate mental health staffing and psychiatric referral provision
Wider context from the report “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral . He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 relapse into depression
Wider context from the report “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised . The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 properly observe ACCT procedures
Wider context from the report “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of suitable psychiatric care facilities
Wider context from the report “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 plan ongoing mental health care and relapse management
Wider context from the report “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur . At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 psychiatric referral and therapeutic medication care planning
Wider context from the report “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures.
” 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 Operational issues concerning proper observance of ACCT procedures should be addressed by NOMS.
Verbatim wording from the response “The specific issues you raise about the failure to properly observe Assessment, Care in Custody & Teamwork (ACCT) procedures are operational and should be addressed by NOMS.” Source location 2016-0220-Response-by-Department-of-Health
Open published response
Concerns raised 2 Failure to ensure continued follow-up of patients with pleural plaques View source Lack of national guidance for follow-up and monitoring of patients with pleural plaques 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
Peter Seale · 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
Peter Seale had occupational asbestos exposure, pleural plaques identified in 2011, and a persistent cough in 2013, but no further tests were conducted before he was diagnosed with terminal lung cancer in 2015. The principal concern was the absence of national guidance for follow-up and monitoring of patients with pleural plaques, creating inconsistent approaches and a risk of patients being lost to follow-up where earlier diagnosis or treatment might be possible.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure continued follow-up of patients with pleural plaques
Wider context from the report “1. There is no national guidance in relation to the follow-up and monitoring of patients with pleural plaques. Medical opinion is split on the issue leading to inconsistency of approach. There is a risk that patients will be ‘lost to follow-up’ in cases where action could be taken to afford early/earlier diagnosis/treatment and thus prevent death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for follow-up and monitoring of patients with pleural plaques
Wider context from the report “1. There is no national guidance in relation to the follow-up and monitoring of patients with pleural plaques. Medical opinion is split on the issue leading to inconsistency of approach. There is a risk that patients will be ‘lost to follow-up’ in cases where action could be taken to afford early/earlier diagnosis/treatment and thus prevent death.
” Open source report
Concerns raised 2 Insufficient ambulance service resources and staffing capacity View source Delays in hospital handover of ambulance patients 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
Peter Scott · 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
Peter Scott suffered an aortic dissection at home on 3 December 2015 and experienced a substantial delay in ambulance attendance after a call was prioritised as Green 2. The principal concern was that resource shortages, frequent use of Capacity Management Plans, recruitment problems and delayed hospital handovers posed a serious risk to the public and could contribute to future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient ambulance service resources and staffing capacity
Wider context from the report “I remain very concerned about resource issues for this ambulance service . I raised similar concerns in a Prevention of Future Deaths Report in the case of MG, dated 11 May 2016.
We heard evidence from a senior manager at EMAS during the inquest. I asked the service to advise me to what extent they had had to invoke Capacity Management Plans in the last 12 months. I was advised that EMAS has had to invoke such a Plan (to at least level 3) for 9 out of the last 12 months .
The issue in this case and that of MG was essentially a matter of resource. In essence, I found that there is only so much an ambulance service can do where they simply do not have an ambulance to send . Demand is clearly greater than the resources they have most of the time , given that a CMP has been in place for 75% of the last 12 month period.
I am very concerned that this poses a serious risk to the public served by this ambulance service . We heard also that recruitment is an ongoing problem – which may be exacerbated by the huge demand placed on its employees by this resource issue.
Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals. I believe the trust is already working to improve this, and I include EMAS in this report in this respect only. Other recipients of the report are required to respond with regard to matters of resourcing only.
1. I consider that there is a risk of future deaths as set out above unless an urgent review of resources is undertaken.
2. Consideration should be given to strategies to improve handover times at hospitals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 handover of ambulance patients
Wider context from the report “I remain very concerned about resource issues for this ambulance service. I raised similar concerns in a Prevention of Future Deaths Report in the case of MG, dated 11 May 2016.
We heard evidence from a senior manager at EMAS during the inquest. I asked the service to advise me to what extent they had had to invoke Capacity Management Plans in the last 12 months. I was advised that EMAS has had to invoke such a Plan (to at least level 3) for 9 out of the last 12 months.
The issue in this case and that of MG was essentially a matter of resource. In essence, I found that there is only so much an ambulance service can do where they simply do not have an ambulance to send. Demand is clearly greater than the resources they have most of the time, given that a CMP has been in place for 75% of the last 12 month period.
I am very concerned that this poses a serious risk to the public served by this ambulance service. We heard also that recruitment is an ongoing problem – which may be exacerbated by the huge demand placed on its employees by this resource issue.
Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals . I believe the trust is already working to improve this, and I include EMAS in this report in this respect only. Other recipients of the report are required to respond with regard to matters of resourcing only.
1. I consider that there is a risk of future deaths as set out above unless an urgent review of resources is undertaken.
2. Consideration should be given to strategies to improve handover times at hospitals.
” Open source report
18 May 2016 Christopher Philip Fields · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to safeguard an injured or intoxicated vulnerable person before police departure View source Failure to protect a witness from an assailant during police information gathering View source Failure of ambulance call-coding algorithms to generate an appropriate Red response for critically injured patients View source Delays in ambulance response to coded emergency calls 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
Christopher Philip Fields · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Philip Fields was attacked twice at his home on 12 December 2014 and sustained fatal head injuries during the second attack. Concerns included police leaving before the ambulance arrived and leaving him in the care of another intoxicated person, a substantial delay in the ambulance response, and ambulance call-coding algorithms that may not have identified the need for a Red response.
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 safeguard an injured or intoxicated vulnerable person before police departure
Wider context from the report “1. The police were called to the address after the first assault had occurred and were still in attendance when the assailant re-entered the premises via the broken window, which he had smashed out of its frame when entering the first time. Despite this rather bizarre set of occurrences, the police then decided to leave the deceased before the ambulance service arrived . Sometime later, the assailant re-entered the flat and beat the deceased to his death.
Various issues arise as a result of the police actions, being why did they leave a vulnerable person in this manner , why did they not await the arrival of the ambulance, why did they not take the witness (female) who was there at the time to a place where she could give them details out of the earshot of the assailant etc., why did they leave an injured and/or intoxicated person in the sole care of another who was also intoxicated , why did they consider it appropriate to accept the view of the injured/intoxicated person as to whether it was safe to leave him in the situation in which he was found ?
Are there issues of training for all GMP officers or did the officers fail to adhere to the approved guidance? (POLICE)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 protect a witness from an assailant during police information gathering
Wider context from the report “1. The police were called to the address after the first assault had occurred and were still in attendance when the assailant re-entered the premises via the broken window, which he had smashed out of its frame when entering the first time. Despite this rather bizarre set of occurrences, the police then decided to leave the deceased before the ambulance service arrived. Sometime later, the assailant re-entered the flat and beat the deceased to his death.
Various issues arise as a result of the police actions, being why did they leave a vulnerable person in this manner, why did they not await the arrival of the ambulance, why did they not take the witness (female) who was there at the time to a place where she could give them details out of the earshot of the assailant etc., why did they leave an injured and/or intoxicated person in the sole care of another who was also intoxicated, why did they consider it appropriate to accept the view of the injured/intoxicated person as to whether it was safe to leave him in the situation in which he was found?
Are there issues of training for all GMP officers or did the officers fail to adhere to the approved guidance? (POLICE)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance call-coding algorithms to generate an appropriate Red response for critically injured patients
Wider context from the report “3. The fact that the call taker coded the call properly and yet this case involved a patient who was clearly critically injured and despite that fact still did not generate a Red response , suggests that the algorithms used for coding are not accurate and not fit for purpose . In my view this is an extremely serious flaw and may/will lead to future deaths occurring unless it is remedied . (NWAS, SECRETARY OF STATE and NHS ENGLAND)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance response to coded emergency calls
Wider context from the report “2. The calls (999) to the ambulance service were properly coded and applied by the call-taker leading to a Green 2 response. This should have led to a vehicle attending within 20 minutes . In the event, the vehicle did not arrive for 2 hours 8 minutes . Why was the response time so dramatically lengthier than prescribed and is this a matter of resources? (NWAS)
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Concerns about AMPDS design should be directed to its private producer, Priority Dispatch Corporation UK Limited.
Verbatim wording from the response “However, please note that AMPDS is produced by the Priority Dispatch Corporation, a private company. If you have concerns about the design of the product you may wish to contact them direct at the following address:” Source location 2016-0194-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ambulance-call coding algorithms are not considered inaccurate or unfit for purpose based on the available case evidence.
Verbatim wording from the response “I therefore do not consider that the algorithms used for coding are inaccurate or unfit for purpose based on the evidence of this case.” Source location 2016-0194-Response-by-Department-of-Health
Open published response
12 May 2016 Mrs Constance Pridmore · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 2 Delays in timely radiologist review and reporting of diagnostic X-rays and CT scans View source Insufficient availability of trained consultant radiologists View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Constance Pridmore · 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
Mrs Constance Pridmore, who was living independently, fell accidentally on 3 May 2015 and was admitted to hospital with pneumonia. She died on 7 May 2015 from a haemothorax associated with fractured ribs, during insertion of a chest drain. The principal concern was that rib fractures and the associated haemothorax were not identified promptly because her admission chest X-ray was not reviewed by a radiologist until after her death, amid a shortage of radiologists.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in timely radiologist review and reporting of diagnostic X-rays and CT scans
Wider context from the report “(1) It was confirmed in evidence by Consultant Radiologist ████████ that:
a) X-rays undertaken on admission to the Accident & Emergency ward at Furness General Hospital are not immediately reviewed by a radiologist , but are assessed by the requesting physician.
b) The X-rays are eventually reviewed by a radiologist on a non-urgent basis when capacity in the system permits . In the case of Mrs Pridmore, her x-ray was reviewed on 11th May 2015, 8 days after being taken and 4 days after she had died.
c) X-rays are not reviewed sooner by a radiologist due to a shortage of available radiologists within the Trust.
(2) It was confirmed in evidence by Consultant Physician ████████ that:
a) If Mrs Pridmore’s x-ray had been reviewed by a radiologist on 3rd May 2015, it is likely that the rib fractures and associated haemothorax would have been identified and that Mrs Pridmore would have been cared for differently.
b) on the balance of probabilities, the outcome for Mrs Pridmore would have been the same due to her age and the nature of her injury. However the failure in identifying the fractures denied Mrs Pridmore the opportunity of a more appropriate course of treatment (e.g. pain management and symptom control) and the possibility, all be it remote, of a different outcome
(3) It was confirmed in evidence by independent Consultant Radiologist, ████████
████████ that:
a) the rib fractures were only discretely visible on the x-ray and would have required a trained radiologist to identify them
b) The shortage of radiologists within the Morecambe Bay trust which prevented Mrs Pridmore’s x-ray from being reviewed by a radiologist sooner is reflective of a critical shortage of radiologists in the U.K.
c) There are presently approximately 400 vacant consultant radiologist posts unfilled in the U.K.
d) the target set in ████████2013 report entitled “NHS Services, Seven days a Week” (Paper NHS121315) for urgent x-rays of inpatients to be completed (including the reporting by a radiologist) within 12 hours is far from being achieved both locally by Morecambe Bay Trust, but also nationally by all Health Trusts . This is due in part to a general increase in the use of scans and x-rays as diagnostic aids, but mainly due to the acute shortage of radiologist who are available and trained to interpret the relevant data accurately and in a timely manner. The Keogh targets whilst intended to become reality by the end of 2016/17 are becoming a more distant ideal than a realistically approaching target.
It is probable that current delays on both a local and national basis in obtaining in a timely manner, accurate radiologist reports of x-rays and CT scans taken for diagnostic purposes , creates a foreseeable risk that further deaths may well arise as a consequence.
Locally, a review of your procedures with regard to the assessment of x-rays is required and nationally, a review into the implementation of the recommendations of the Keogh report is likely to be necessary.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 trained consultant radiologists
Wider context from the report “(1) It was confirmed in evidence by Consultant Radiologist ████████ that:
a) X-rays undertaken on admission to the Accident & Emergency ward at Furness General Hospital are not immediately reviewed by a radiologist, but are assessed by the requesting physician.
b) The X-rays are eventually reviewed by a radiologist on a non-urgent basis when capacity in the system permits. In the case of Mrs Pridmore, her x-ray was reviewed on 11th May 2015, 8 days after being taken and 4 days after she had died.
c) X-rays are not reviewed sooner by a radiologist due to a shortage of available radiologists within the Trust.
(2) It was confirmed in evidence by Consultant Physician ████████ that:
a) If Mrs Pridmore’s x-ray had been reviewed by a radiologist on 3rd May 2015, it is likely that the rib fractures and associated haemothorax would have been identified and that Mrs Pridmore would have been cared for differently.
b) on the balance of probabilities, the outcome for Mrs Pridmore would have been the same due to her age and the nature of her injury. However the failure in identifying the fractures denied Mrs Pridmore the opportunity of a more appropriate course of treatment (e.g. pain management and symptom control) and the possibility, all be it remote, of a different outcome
(3) It was confirmed in evidence by independent Consultant Radiologist, ████████
████████ that:
a) the rib fractures were only discretely visible on the x-ray and would have required a trained radiologist to identify them
b) The shortage of radiologists within the Morecambe Bay trust which prevented Mrs Pridmore’s x-ray from being reviewed by a radiologist sooner is reflective of a critical shortage of radiologists in the U.K.
c) There are presently approximately 400 vacant consultant radiologist posts unfilled in the U.K.
d) the target set in ████████2013 report entitled “NHS Services, Seven days a Week” (Paper NHS121315) for urgent x-rays of inpatients to be completed (including the reporting by a radiologist) within 12 hours is far from being achieved both locally by Morecambe Bay Trust, but also nationally by all Health Trusts. This is due in part to a general increase in the use of scans and x-rays as diagnostic aids, but mainly due to the acute shortage of radiologist who are available and trained to interpret the relevant data accurately and in a timely manner . The Keogh targets whilst intended to become reality by the end of 2016/17 are becoming a more distant ideal than a realistically approaching target.
It is probable that current delays on both a local and national basis in obtaining in a timely manner, accurate radiologist reports of x-rays and CT scans taken for diagnostic purposes, creates a foreseeable risk that further deaths may well arise as a consequence.
Locally, a review of your procedures with regard to the assessment of x-rays is required and nationally, a review into the implementation of the recommendations of the Keogh report is likely to be necessary.
” 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 Urgent and emergency care networks are responsible for developing clinical pathways, designating services and monitoring performance and access.
Verbatim wording from the response “NHS England reports that the Urgent and Emergency Care Review arising from Sir Bruce Keogh’s work is now in its implementation phase. Key to implementation is the development of urgent and emergency care (UEC) networks. In June 2015, NHS England published guidance for what were then emerging networks titled Role and Establishment of Urgent and Emergency Care Networks and in October a total of 23 UEC networks across the four regions of NHS England were confirmed.” Source location 2016-0491-Response-by-Department-of-Health
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 Responsibility for staffing levels and skill mix rests with individual NHS Trust boards, considering local factors and safe-care requirements.
Verbatim wording from the response “Responsibility for staffing rests, as it has always done, with Trust boards. Trusts should focus on the numbers and skill mix needed to deliver quality care, patient safety and efficiency, taking into account local factors such as acuity and case mix.” Source location 2016-0491-Response-by-Department-of-Health
Open published response
11 May 2016 Gillian Rose Taylor · Prevention of Future Deaths report South Wales Central
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Concerns raised 4 Increased risk of self-harm or suicide following adverse experiences of sectioning View source Lack of continuity of treatment View source Lack of an acute treatment facility for acute admission patients in Powys View source Lack of an acute treatment facility for acutely unwell patients in Powys View source See 1 more concern
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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
Gillian Rose Taylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Gillian Rose Taylor had a lengthy history of mental health issues and repeated suicide attempts. After being detained under the Mental Health Act and treated away from Powys because no acute bed was available locally, she remained under community mental health care until her death by hanging at home on 3 January 2016. The concerns included the lack of an acute treatment facility in Powys, resulting patient transfers, lack of continuity of treatment, and the possible adverse effect of this experience on her engagement with mental health professionals and risk of self-harm or suicide.
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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 Increased risk of self-harm or suicide following adverse experiences of sectioning
Wider context from the report “(3) The evidence showed that, on balance, it is likely that the experience of being sectioned in these circumstances had an adverse effect upon Mrs Taylor which fuelled an unwillingness, on her part, to engage with Mental Health professionals thereby increasing her risk of self harm/suicide .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of continuity of treatment
Wider context from the report “(2) As a consequence of 1 above there is often a lack of continuity of treatment which can be to the detriment of the patient concerned.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of an acute treatment facility for acute admission patients in Powys
Wider context from the report “(4) It is believed that Powys Health Board is the only Health Board in the country that has no facility available to it for the treatment of acute admission patients in the position of Mrs Taylor.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of an acute treatment facility for acutely unwell patients in Powys
Wider context from the report “(1) There is no acute facility in Powys for the treatment of acutely unwell patients , which the evidence showed, often leads to patients being moved the length and breadth of the country to an establishment where a bed can be found. The evidence also showed that the local acute unit at the Redwoord Centre in Shrewsbury had recently experienced a significant reduction in the number of acute beds available compounding and exacerbating the problem.
” Open source report
3 May 2016 Darren Mindham · Prevention of Future Deaths report South London
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Concerns raised 1 Lack of strict control over pentobarbital View source
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AI-generated summary
Darren Mindham · 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
Darren Mindham, who worked as an assistant in a veterinary practice, died by suicide after self-administering pentobarbital at home on 28 August 2015. The principal concern was that pentobarbital was subject to less strict controls, and that access to it may facilitate suicide.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of strict control over pentobarbital
Wider context from the report “Pentobarbital is a drug that is found in Schedule 3 of the Misuse of Drugs Regulations 2001, and is therefore not subject to the strict control found in Schedule 2. Whilst there may be practical difficulties in complying with stricter control, the use of pentobarbital in suicide has become commonplace . It has been shown that reducing access to the means of suicide can be effective in reducing the rate of suicide.
” 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 Drug classification and scheduling are not matters for the Department of Health.
Verbatim wording from the response “This is not however a matter for the Department of Health. The Advisory Council on the Misuse of Drugs (ACMD) makes recommendations to government on the control of dangerous or otherwise harmful drugs, including classification and scheduling under the Misuse of Drugs Act 1971 and its regulations. ACMD is an advisory non-departmental public body, sponsored by the Home Office and is the lead organisation in this area. I would therefore advise that you re-direct your Regulation 28 letter to the following contact for a response on this matter.” Source location 2016-0170-Response-by-Department-of-Health
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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 Advisory Council on the Misuse of Drugs, sponsored by the Home Office, is responsible for recommendations on drug classification and scheduling.
Verbatim wording from the response “This is not however a matter for the Department of Health. The Advisory Council on the Misuse of Drugs (ACMD) makes recommendations to government on the control of dangerous or otherwise harmful drugs, including classification and scheduling under the Misuse of Drugs Act 1971 and its regulations. ACMD is an advisory non-departmental public body, sponsored by the Home Office and is the lead organisation in this area. I would therefore advise that you re-direct your Regulation 28 letter to the following contact for a response on this matter.” Source location 2016-0170-Response-by-Department-of-Health
Open published response
Concerns raised 1 Insufficient availability of specialist neurological care 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
Marina Fagan · 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
Marina Fagan was admitted to hospital with headaches, later developed confusion, visual loss and eye movement palsy, and was diagnosed with PRES before dying on 6 October 2015. The report raised concerns about the availability of specialist neurological care, including delays in neurology input and limited out-of-hours neurologist provision, and noted that future deaths could occur in similar circumstances.
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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 specialist neurological care
Wider context from the report “This witness set out his concern that, nationwide, there are insufficient neurologists to provide necessary specialist care . He noted that in the out of hours setting, although there were neurologists available the nearby tertiary care hospital, none were on-call in the hospital to which Ms Fagan was initially admitted .
Ms Fagan's general practitioner set out that the current waiting time to see a neurologist in the outpatient setting, is 72 days .
Given the issues regarding availability of specialist neurological care, I am concerned that future deaths will occur in similar circumstances.
” 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 Barts Health NHS Trust is responsible for addressing local neurologist availability and staffing levels.
Verbatim wording from the response “It is the responsibility of providers to ensure that they have appropriate staffing levels to meet the needs of their patients. The availability of neurologists locally is therefore for Barts Health NHS Trust to address.” Source location 2016-0162-Response-by-Department-of-Health
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Health Education England is responsible for planning the national neurology workforce and commissioning training places.
Verbatim wording from the response “On a national basis, Health Education England (HEE) plans the future workforce. HEE has consistently invested in the commissioning of training places in neurology and intends to commission 219 training places in 2016/17, a small rise from 217 in both 2014/15 and 2015/16.” Source location 2016-0162-Response-by-Department-of-Health
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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 National neurology waiting times meet the operational NHS waiting-time standard, so existing arrangements address the national concern.
Verbatim wording from the response “Where this is not possible, the NHS should take all reasonable steps to offer a range of suitable alternative providers able to see or treat the patient more quickly than the original provider, if this is what the patient wants and it is clinically appropriate. Commissioners are not obliged to take all reasonable steps to find an alternative provider if the patient does not ask for this. Some patients will wait longer than 18 weeks by choice, for personal or social reasons, or because this is clinically appropriate.” Source location 2016-0162-Response-by-Department-of-Health
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations