3 Nov 2014 SANDRA HAZEL ELIZABETH HIGHAM · Prevention of Future Deaths report London (Inner South)
View report summary
Concerns raised 3 Lack of awareness among the wider medical profession of atrial-oesophageal fistula as an ablation risk View source Difficulty diagnosing atrial-oesophageal fistula in acute medical settings View source Risk of atrial-oesophageal fistula following ablation procedures View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
SANDRA HAZEL ELIZABETH HIGHAM · 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
Sandra Hazel Elizabeth Higham died at St Thomas's Hospital, London, on 7 December 2013 after developing an atrial-oesophageal fistula following an ablation procedure for atrial fibrillation. The principal concerns were that this rare but known complication can be difficult to diagnose because of non-specific symptoms and limited awareness, and that early diagnosis, prompt surgery and prolonged antibiotic therapy may be important for survival.
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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 awareness among the wider medical profession of atrial-oesophageal fistula as an ablation risk
Wider context from the report “(4) According to the literature there are no clear predictors of mortality from an atrial-oesophageal fistula, but early diagnosis, prompt surgical intervention and prolonged antibiotic therapy may be crucial for survival.
(5) Diagnosing an atrial-oesophageal fistula can be difficult, especially in an acute medical setting, given its range of non-specific symptoms and duration of onset, and the lack of awareness within the wider medical profession of such a fistula being a risk of the ablation procedure .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Difficulty diagnosing atrial-oesophageal fistula in acute medical settings
Wider context from the report “(4) According to the literature there are no clear predictors of mortality from an atrial-oesophageal fistula, but early diagnosis, prompt surgical intervention and prolonged antibiotic therapy may be crucial for survival.
(5) Diagnosing an atrial-oesophageal fistula can be difficult , especially in an acute medical setting, given its range of non-specific symptoms and duration of onset , and the lack of awareness within the wider medical profession of such a fistula being a risk of the ablation procedure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 atrial-oesophageal fistula following ablation procedures
Wider context from the report “(2) The development of an atrial-oesophageal fistula is a very rare, but known, risk of the ablation procedure (developing in around 0.01-0.2% of cases of percutaneous ablation and around 1-1.5% of cases of surgical ablation).
(3) If an atrial-oesophageal fistula does develop, it has a very high mortality rate (reported to be 67-100%).
” 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 British Cardiovascular Society is best placed to respond to concerns about atrial-oesophageal fistula and circulate guidance to relevant surgeons.
Verbatim wording from the response “The SCTS suggested that both cardiologists and electro-physiologists, through the BCS, were best placed to respond to your concerns and suggested that BCS could prepare a letter to be circulated to the upper gastrointestinal surgeons, thoracic surgeons and cardiac surgeons.” Source location 2014-0479-Response-by-Department-of-Health
Open published response
Concerns raised 4 Unsafe retail display of button batteries accessible to small children View source Lack of lockable battery compartments in non-toy torches View source Lack of knowledge about managing incidents involving ingested button batteries View source Insufficient national awareness of the risks of ingested button batteries 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
Eliza Bashir · 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
Eliza Bashir swallowed a button battery from a torch on 22 March 2013. Although the battery was removed and she remained well for almost a week, she collapsed on 30 March 2013 and died after resuscitation failed. Concerns included the lack of a lockable battery compartment because the torch was not classified as a toy, uncertainty among clinicians about managing such incidents, and the accessibility and sale of button batteries to young children.
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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 Unsafe retail display of button batteries accessible to small children
Wider context from the report “4. Concern remains that such batteries are sold in supermarkets and other retail establishments and are often on display at a level that would enable small children to gain access to them whilst unobserved .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 lockable battery compartments in non-toy torches
Wider context from the report “1. Evidence from the Trading Standards Officer confirmed that because the torch was not classified as a toy, it did not require a lockable battery compartment , notwithstanding compliance with safety regulations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 knowledge about managing incidents involving ingested button batteries
Wider context from the report “2. Consultant Paediatric Surgeon frankly asserted that both he and his colleagues were still worried as they did not know how best to deal with incidents such as this and whilst awareness of the risks and complications arising from ingested button batteries were being raised locally, there was a need for the profile of those risks to be raised nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient national awareness of the risks of ingested button batteries
Wider context from the report “2. Consultant Paediatric Surgeon frankly asserted that both he and his colleagues were still worried as they did not know how best to deal with incidents such as this and whilst awareness of the risks and complications arising from ingested button batteries were being raised locally, there was a need for the profile of those risks to be raised nationally .
” 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 Share button-battery risk information with health visitors, school nurses and regional Public Health England child-health leads.
Verbatim wording from the response “However, I will ensure that the information in your letter and this reply is shared with health visitors, school nurses and the child health leads at Public Health England’s regional centres so that awareness of the risks of button batteries is further raised. My officials will give consideration as to how these professionals can best be supported to use this information to make parents and child carers aware of this issue.” Source location 2014-0461-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 Consider how best to support health professionals in using button-battery information to inform parents and child carers.
Verbatim wording from the response “However, I will ensure that the information in your letter and this reply is shared with health visitors, school nurses and the child health leads at Public Health England’s regional centres so that awareness of the risks of button batteries is further raised. My officials will give consideration as to how these professionals can best be supported to use this information to make parents and child carers aware of this issue.” Source location 2014-0461-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 Share the coroner’s report with Department for Business, Innovation and Skills colleagues to address retail button-battery safety concerns.
Verbatim wording from the response “Although your concern relating to the display and placement of button batteries in retail outlets is a matter for the retailers concerned, my officials have however, shared a copy of your report with colleagues in the Department of Business, Innovation and Skills (BIS). I expect them to liaise with the Royal Society for the Prevention of Accidents (RoSPA) and the National Trading Standards Board (NTSB) to explore a way to address this concern with retailers.” Source location 2014-0461-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Retailers are responsible for addressing the display and placement of button batteries in retail outlets.
Verbatim wording from the response “Although your concern relating to the display and placement of button batteries in retail outlets is a matter for the retailers concerned, my officials have however, shared a copy of your report with colleagues in the Department of Business, Innovation and Skills (BIS). I expect them to liaise with the Royal Society for the Prevention of Accidents (RoSPA) and the National Trading Standards Board (NTSB) to explore a way to address this concern with retailers.” Source location 2014-0461-Response-by-Department-of-Health
Open published response
24 Oct 2014 Isa Riaz Mushtaq · Prevention of Future Deaths report Manchester (City)
View report summary
Concerns raised 2 Unavailability of fetal blood sampling for antenatal CTG assessment View source Lack of detailed national guidance on antepartum CTG assessment and management View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Isa Riaz Mushtaq · 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
Isa Riaz Mushtaq was delivered by emergency caesarean section after reduced fetal movement, a suspicious antenatal CTG and fetal bradycardia. He did not recover from the bradycardia/asystole episode, developed severe hypoxic ischaemic encephalopathy and died on the third neonatal day. The principal concern was the absence of detailed national guidance for interpreting and managing abnormal antenatal CTGs, including when urgent delivery is required.
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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 Unavailability of fetal blood sampling for antenatal CTG assessment
Wider context from the report “In clinical practice the fetal CTG continues to be a source of problems, both in interpretation and in what degree of action should be taken. This is particularly the case for antenatal (non labour) CTG’s since there has not been the same clarification that was provided for electronic intrapartum fetal monitoring by specific NICE guidance. Currently there is no detailed national guidance on antepartum CTG assessment and therefore no guidance as to the circumstances in which CTG changes or abnormalities require urgent delivery. For example, the following problems with antenatal CTG interpretation may arise:-
(i) Should change of position or intravenous fluids be used in the same way as in labour
(ii) What role can be given to iced water drinks or dietary intake to stimulate fetal changes
(iii) At what stage should intervention should be made and with what urgency in the absence of decelerations.
(iv) What significance should be attached to reduced variability and what action should be taken in the absence of decelerations
(v) What significance should be attached to the absence of accelerations where there is reduced variability.
Reliance on the NICE guidance for intrapartum CTG monitoring to interpret antenatal CTG features is of limited value because:
(i) It is not intended for such use and therefore such practice is arguably not evidence based
(ii) It is much more common for fetal heart traces not to look normal during labour (in the region 20 -30 % outwith normal parameters) therefore the significance of such abnormal traces may not be the same in labour as compared to when identified antenatally.
(iii) Only a very small percentage of antenatal CTG’s are not normal.
(iv) There is no recourse to fetal blood sampling for an antenatal CTG, so that if suspicions persist about lack of fetal well-being there is no way of assessing fetal acid-base balance.
St Mary’s Hospital has now developed its own local guidance for the management of suspected abnormal antenatal CTG in order to mitigate risk. In the absence of uniform, detailed national guidance on antepartum CTG abnormalities St Mary’s hospital has implemented a procedure of early consultant involvement where there are persisting features of unusual CTG.
There should be a review to consider whether national guidance on antepartum CTG monitoring and interpretation where there are abnormalities or unusual features would lead to safer, evidence based management of such cases.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 detailed national guidance on antepartum CTG assessment and management
Wider context from the report “In clinical practice the fetal CTG continues to be a source of problems, both in interpretation and in what degree of action should be taken. This is particularly the case for antenatal (non labour) CTG’s since there has not been the same clarification that was provided for electronic intrapartum fetal monitoring by specific NICE guidance . Currently there is no detailed national guidance on antepartum CTG assessment and therefore no guidance as to the circumstances in which CTG changes or abnormalities require urgent delivery . For example, the following problems with antenatal CTG interpretation may arise:-
(i) Should change of position or intravenous fluids be used in the same way as in labour
(ii) What role can be given to iced water drinks or dietary intake to stimulate fetal changes
(iii) At what stage should intervention should be made and with what urgency in the absence of decelerations.
(iv) What significance should be attached to reduced variability and what action should be taken in the absence of decelerations
(v) What significance should be attached to the absence of accelerations where there is reduced variability.
Reliance on the NICE guidance for intrapartum CTG monitoring to interpret antenatal CTG features is of limited value because:
(i) It is not intended for such use and therefore such practice is arguably not evidence based
(ii) It is much more common for fetal heart traces not to look normal during labour (in the region 20 -30 % outwith normal parameters) therefore the significance of such abnormal traces may not be the same in labour as compared to when identified antenatally.
(iii) Only a very small percentage of antenatal CTG’s are not normal.
(iv) There is no recourse to fetal blood sampling for an antenatal CTG, so that if suspicions persist about lack of fetal well-being there is no way of assessing fetal acid-base balance.
St Mary’s Hospital has now developed its own local guidance for the management of suspected abnormal antenatal CTG in order to mitigate risk. In the absence of uniform, detailed national guidance on antepartum CTG abnormalities St Mary’s hospital has implemented a procedure of early consultant involvement where there are persisting features of unusual CTG.
There should be a review to consider whether national guidance on antepartum CTG monitoring and interpretation where there are abnormalities or unusual features would lead to safer, evidence based management of such cases.
” Open source report
20 Oct 2014 Samuel Duckworth · Prevention of Future Deaths report Inner South London
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Concerns raised 1 Unrestricted internet access to prescription-only drugs without medical supervision View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Samuel Duckworth · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Samuel Duckworth was found dead in his flat after taking an overdose of Diazepam, Codeine and alcohol; the inquest recorded the medical cause of death as Diazepam, Codeine and Alcohol intoxication. The principal concern was that he could readily purchase prescription-only drugs on the internet, with the report identifying this as an ongoing risk to other vulnerable people whose medication should be medically supervised.
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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 Unrestricted internet access to prescription-only drugs without medical supervision
Wider context from the report “Mr Duckworth had consulted a psychiatrist and offered help with alcohol withdrawal and psychological therapies for mood swings, anxiety and impulse control. He was only prescribed a small amount of Diazepam, which I infer is because of the risks of abuse. Yet he had no difficulty in purchasing these prescription only drugs on the internet , 20 empty packets being found at the scene.
No evidence was admitted as to whether such access could be restricted or regulated . The ease of access clearly constitutes an on going risk to the lives of other vulnerable people, whose medication should be medically supervised .
” Open source report
17 Oct 2014 Yaser Saleh · Prevention of Future Deaths report Inner South London
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Concerns raised 1 Failure of computerised recall systems to identify chronic disease patients requiring review beyond current prescribing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Yaser Saleh · 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
Yaser Saleh, aged 15, died on 13 September 2012 after collapsing with cardio-respiratory arrest from acute asthma. The report raised concerns that electronic systems did not identify asthma patients needing review when they were no longer receiving regular prescriptions, creating a risk of preventable deaths in people with chronic diseases.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of computerised recall systems to identify chronic disease patients requiring review beyond current prescribing
Wider context from the report “The GP reported that she believes that her EMIS computer system only called up people for review who were receiving regular prescriptions and thus a patient who had been on regular treatment but no longer was asking for inhalers was not identified as requiring call up for review. Whilst the court heard it was possible to customize the QOF system to call up patients, there was, according to the GP, no computerised system of calling up asthmatics who needed review unless they were currently on regular medication . She and the consultant in emergency medicine considered this created a risk of preventable deaths, that merited my making this report. The consultant in emergency medicine also said that this risk applied to other chronic diseases, such as epilepsy.
This risk of not identifying those at risk of death because they no longer comply or have not been prescribed treatment taken in the past brought to the attention of EMIS and the Secretary of State, to consider whether EMIS has the potential or another electronic system should be commissioned to ensure that those with chronic disease requiring review and monitoring, are triggered for the attention of the GP, on wider criteria than current prescribing , or if such a system is available that the Department considers using it and other GPs are made aware of its use.
” Open source report
13 Oct 2014 Mary Fenton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 12 Failure to assess patients’ mental capacity View source Failure to document unavailable consent or self-consenting rationale View source Unavailability of specialist cardiology advice outside normal hours View source Fragility of the national pharmaceutical supply chain View source Lack of adequate facilities to manage complications of pacing placement View source Unavailability of skilled and qualified staff to fit pacing wires View source Delays in inserting pacing wires View source Failure to obtain consent to treatment View source Failure to document patients’ mental capacity View source Severe shortages of Isoprenaline View source Unavailability of echocardiography facilities after 5.00pm View source Failure of communication between staff, patients and families View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mary Fenton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mary Fenton was admitted to Tameside Hospital on 26 April 2014 needing an urgent heart pacemaker and died on 30 April 2014 after delays and missed opportunities. Concerns included limited cardiology cover and facilities, shortages of Isoprenaline, failures relating to capacity and consent, delays in inserting pacing wires, inadequate facilities to manage complications, and poor communication.
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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 patients’ mental capacity
Wider context from the report “4. There was a failure of the medical staff to assess and/or document the mental “capacity” of the patient (For Tameside Hospital)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to document unavailable consent or self-consenting rationale
Wider context from the report “5. There was a failure of the medical staff to obtain “consent” to treatment or to document why such consent was unavailable and why they were “self-consenting” . (For Tameside Hospital)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of specialist cardiology advice outside normal hours
Wider context from the report “1. Although Tameside Hospital holds itself out as performing pacemaker insertions, both temporary and permanent, no Cardiology Consultant is on call after 5.00pm or at week-ends . There is therefore no-one available to the junior staff having the requisite levels of skill and expertise to advise . (For Tameside Hospital)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Fragility of the national pharmaceutical supply chain
Wider context from the report “9. The National pharmaceutical supply chain was described in evidence by a Chief Pharmacist as being “very fragile” (For Secretary of State)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 facilities to manage complications of pacing placement
Wider context from the report “8. It was demonstrated by the evidence that if there should be a situation where the placing of the pacing causes unforeseen problems (e.g. by causing bleeding within the pericardium leading to cardiac tamponade) there is a lack of adequate facilities to address that situation . (For Tameside Hospital)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of skilled and qualified staff to fit pacing wires
Wider context from the report “6. Despite this being a major District General Hospital providing cardiology cover for a large proportion of the population of Greater Manchester, there is no-one with the skill or qualification to fit “temporary/permanent” pacing wires . (For Tameside Hospital)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in inserting pacing wires
Wider context from the report “7. There were inexcusably and potentially catastrophic delays in inserting the pacing wires (For Tameside Hospital)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain consent to treatment
Wider context from the report “5. There was a failure of the medical staff to obtain “consent” to treatment or to document why such consent was unavailable and why they were “self-consenting”. (For Tameside Hospital)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to document patients’ mental capacity
Wider context from the report “4. There was a failure of the medical staff to assess and/or document the mental “capacity” of the patient (For Tameside Hospital)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Severe shortages of Isoprenaline
Wider context from the report “3. This patient was being kept alive by the use of Isoprenaline. It transpires that there were severe shortages of this drug in the hospital but also nationally . I was told that this drug is produced as an unlicensed drug by NHS Pharmaceutical Productions. If so why do they not ensure sufficient supply? (For Tameside Hospital and for The Secretary of State)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 echocardiography facilities after 5.00pm
Wider context from the report “2. After 5.00pm there is no facility for an echocardiogram to be performed at the hospital. (For Tameside Hospital)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between staff, patients and families
Wider context from the report “10. There was very poor communication between staff and other staff, and between staff and the family of the deceased and the patient herself (e.g. in relation to DNAR notice, “consent” forms etc.) (Tameside Hospital).
” 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 Work with European and North American countries to resolve pharmaceutical supply issues.
Verbatim wording from the response “Supply issues are complex and most have to be dealt with on a case by case basis but in recognising the main problems it is possible to take action to mitigate them. Our Government is currently working with other countries in Europe and with North America to resolve some of these supply issues.” Source location 2014-0443-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 Ask the NHS UK Medicines Information service to produce a shortage memorandum on isoprenaline availability and alternative supply sources.
Verbatim wording from the response “The Department of Health is aware that there have been problems with the availability of isoprenaline and that earlier this year the NHS PMUs experienced problems obtaining the active pharmaceutical ingredient. The Department of Health therefore asked the NHS UK Medicines Information service (UKMI) to produce a “Shortage Memo” which summarises the situation and advises on alternative sources of supply. This was sent out to hospitals and uploaded to the UKMI website, at the following address, on 24 April 2014:-” Source location 2014-0443-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Some medicine supply problems are inevitable and unavoidable because of manufacturing, regulatory and raw-material difficulties.
Verbatim wording from the response “Medicines shortages are not new, nor are they confined to the UK. There are a number of reasons why such shortages do arise but the two main reasons are commonly referred to as ‘upstream’ and ‘downstream’:-” Source location 2014-0443-Response-by-Department-of-Health
Open published response
Concerns raised 3 Lack of a framework for primary care staff to decide when an interpreter is required View source Lack of a flagging system to alert primary care staff to consider one patient's care in the context of another patient's care View source Unavailability of interpreters to primary care staff when needed View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Chloe Siokos · 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
Chloe Siokos was found dead at her home on 22 January 2013 after her husband set a fire in the house and then hanged himself; the inquest concluded unlawful killing. The report identifies concerns about the absence of a framework for deciding when primary care interpreters are required, limited interpreter availability, and the lack of a system flagging when one patient's circumstances may affect care provided to another patient.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a framework for primary care staff to decide when an interpreter is required
Wider context from the report “That there was no framework for primary care staff to make a decision when an interpreter is required .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a flagging system to alert primary care staff to consider one patient's care in the context of another patient's care
Wider context from the report “That there is no system of flagging to alert primary care staff to the need to consider the care provided to a patient in the context of another patient where that is relevant .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 interpreters to primary care staff when needed
Wider context from the report “That interpreters should be available to primary care staff more readily
” Open source report
9 Sep 2014 Joyce Nelson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to document imaging results View source Unsafe discharge decisions despite significant injury View source Delays in reporting imaging results View source Delays in emergency medical 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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Joyce Nelson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joyce Nelson fell at home on 7 March 2014 and fractured her pelvis in several places. The report raises concerns about delays in medical assessment, documentation and imaging results at the Emergency Department, and that she was to be discharged despite having a multi-fractured pelvis; it states that the delays were linked to reported shortages of emergency medicine doctors and radiologists.
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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 document imaging results
Wider context from the report “2. Chest and hip X-rays were carried out but the results were not documented by the doctor who was simply too busy to do so.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 discharge decisions despite significant injury
Wider context from the report “3. Patient was to be discharged (even though it was later shown that she had a multi-fractured pelvis ).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 reporting imaging results
Wider context from the report “4. There were very considerable delays in reporting the imaging results , and I was told that this is due to a national shortage of Radiologists.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in emergency medical assessment
Wider context from the report “1. She was admitted to the Emergency Department at Stepping Hill Hospital shortly after midnight yet was not assessed by a doctor until 04.10 hours . I was told that the Department was fully staffed but there is a national shortage of Doctors specialising in emergency medicine.
” Open source report
Concerns raised 4 Unavailability of a double-crewed ambulance during meal break windows View source Lack of manager notification when a crew unilaterally stands off and support is likely to be delayed View source Lack of training for Emergency Medical Dispatch staff to recognise signs of respiratory difficulty View source Failure of the stand-off process to ensure automatic consideration of all alternative support methods View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Anthony Offord · 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
Anthony Offord collapsed at a friend's flat on 16 April 2013 and died two days later from hypoxic brain injury following a delay in providing support to a lone responder. The report raised concerns about the lack of consideration of alternative support, the absence of a requirement to involve a manager when a stand-off caused delay, and insufficient training for emergency medical dispatch staff to recognise signs of respiratory difficulty such as snoring in an unresponsive person.
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 a double-crewed ambulance during meal break windows
Wider context from the report “(5) With some diffidence, the point should also be raised that apart from the other lone responders who were available, as referred to in ‘Circumstances of the Death’ above, there was another double crewed ambulance nearby which could very likely have reached the scene as early as 2310 -- a point at which Mr Offord might have been saved. Unfortunately at 2302 this vehicle had become 'unavailable out of meal break window' . I recognise that this is a difficult subject, with valid arguments on both sides. I appreciate that it is a national issue, much debated in the past, and I do no more here than record the position as regards that vehicle.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 manager notification when a crew unilaterally stands off and support is likely to be delayed
Wider context from the report “(2) That where crew make a unilateral decision to stand off there is no requirement for a manager to be informed, even when there is likely to be a delay in the provision of 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 training for Emergency Medical Dispatch staff to recognise signs of respiratory difficulty
Wider context from the report “(1) There is (apparently) no training given to Emergency Medical Dispatch staff as to signs of respiratory difficulty including the well known relevance of snoring in a person who cannot be roused . This may perhaps require an amendment to the breathing diagnostic tool?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of the stand-off process to ensure automatic consideration of all alternative support methods
Wider context from the report “(3) That there is no system to ensure that all alternative methods of support are automatically considered when a stand-off occurs , not simply a double crewed ambulance.
” Open source report
Concerns raised 2 Lack of standardised documentation View source Failure to maintain effective communication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jude Daniel Kliem · 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
Jude Daniel Kliem was being treated at Derriford Hospital, where attempts were made to arrange a transfer to Bristol and Southampton. The report identified an apparent breakdown in communication and possible improvement through standardised documentation.
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 standardised documentation
Wider context from the report “There appears to have been a breakdown in communication. There could be an improvement by way of standardisation of documentation
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 effective communication
Wider context from the report “There appears to have been a breakdown in communication . There could be an improvement by way of standardisation of documentation
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a national referral and retrieval format as part of a process supporting senior clinical discussion and agreement on appropriate action.
Verbatim wording from the response “There is clearly an opportunity to further improve safety by bringing together the best aspects of the existing formats into a single document. Such a document would contain the key content needed for safe and effective referral and retrieval, to which suitable local or specialist requirements might be added.” Source location 2014-0464-Response-by-Department-of-Health
Open published response
14 Aug 2014 Thomas Warren · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Lack of regulatory monitoring and review of incomplete remediation referrals before subsequent locum employment View source Failure to secure complete employment histories, references and fitness to practise information for long-term locum doctors View source Unavailability of GMC-held fitness to practise and NCAS referral information to subsequent enquirers View source Failure to place provisional registration conditions when an NCAS assessment is at risk of remaining incomplete View source Lack of clarity over responsibility for enquiring into previous fitness to practise concerns and NCAS referrals when recruiting short-notice locum doctors View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Thomas Warren · 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
Thomas Warren, a child with cerebral palsy, died after receiving a 25 microgram fentanyl patch for pain and subsequently developing symptoms before suffering a cardiac arrest. The report identified concerns about prescribing an opiate to an opiate-naïve child without hospital admission, missed opportunities to stop dispensing the drug and provide parents with adequate monitoring information, and gaps in checks on the fitness to practise of a locum doctor.
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 regulatory monitoring and review of incomplete remediation referrals before subsequent locum employment
Wider context from the report “(4) There did not appear to be any regulatory mechanism for monitoring or reviewing cases where the doctor no longer works for the Trust where a remediation referral was made and NCAS (or other body) assessment is not completed, before subsequent locum employment. Revalidation requirements might not be an effective mechanism for employment of short notice locum vacancies.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 secure complete employment histories, references and fitness to practise information for long-term locum doctors
Wider context from the report “(2) There are particular difficulties with securing a complete sequence of employment and the associated references and confirmation about concerns for fitness to practice of long term locum doctors who may have gaps between jobs or worked abroad . Thus serious concerns about practice may have existed but not come to notice of the Agency or prospective employing NHS Trust .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of GMC-held fitness to practise and NCAS referral information to subsequent enquirers
Wider context from the report “(3) Crucial information was held by the GMC about concerns about this doctor’s fitness to practice, including his referral to NCAS. This information was not available to those enquiring about his fitness to practice at a subsequent time. Nor was any provisional condition placed on his registration, having learnt that he was leaving the NHS so that the NCAS assessment was at risk of being in abeyance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to place provisional registration conditions when an NCAS assessment is at risk of remaining incomplete
Wider context from the report “(3) Crucial information was held by the GMC about concerns about this doctor’s fitness to practice, including his referral to NCAS. This information was not available to those enquiring about his fitness to practice at a subsequent time. Nor was any provisional condition placed on his registration, having learnt that he was leaving the NHS so that the NCAS assessment was at risk of being in abeyance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 over responsibility for enquiring into previous fitness to practise concerns and NCAS referrals when recruiting short-notice locum doctors
Wider context from the report “(1) There does not appear to be clarity as to who or which organization should enquire into previous fitness to practice concerns and referrals to NCAS (or successor organization) which have not led to restrictions or conditions of registration by the GMC when locum doctors are being recruited by an Agency at short notice by prospective NHS Trusts. In this case it appears that neither the Recruitment Agency nor Trust nor consultant asked the doctor before his employment began.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a high-level Secondary Care Locum Doctor Working Group and obtain recommendations to strengthen locum-doctor recruitment and quality assurance.
Verbatim wording from the response “In November 2013, I established a high level Secondary Care Locum Doctor Working Group. This made a series of recommendations to Government to strengthen the existing arrangements:” Source location 2014-0378-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 Locum agencies and healthcare providers are responsible for checking doctors’ fitness and suitability, with ultimate responsibility resting with the employer.
Verbatim wording from the response “It is the responsibility of both the locum agency and the healthcare provider to check a doctor is up to date, fit to practise and suitable for a specific post. Ultimately, the employer is responsible for the staff it employs, but if an agency is involved, the agency should apply the same checks as the Trust itself would if employing directly.” Source location 2014-0378-Response-by-Department-of-Health
Open published response
Concerns raised 7 Failure to examine patients prior to chest drain insertion View source Incorrect interpretation of the cardiac silhouette View source Misinterpretation of chest x-rays View source Failure to use a lead anatomical marker when taking chest x-rays View source Failure by clinicians to identify incorrectly labelled chest x-rays View source Failure to consider both chest x-rays View source Incorrect labelling of chest x-rays View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Gerald Trevor WERRETT · 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
Gerald Trevor Werrett was admitted to hospital with an infective exacerbation of chronic obstructive airways disease and other co-morbidities. During treatment, a chest drain was mistakenly inserted on the left instead of the right after chest X-rays were inverted, mislabelled and misinterpreted. The inquest concluded that he died from bilateral bronchopneumonia, chronic obstructive airways disease and ischaemic heart disease, with his death contributed to by the misplaced chest drain; concerns included failures in X-ray marking, labelling, interpretation, review and examination before insertion.
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 examine patients prior to chest drain insertion
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered.
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Incorrect interpretation of the cardiac silhouette
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered.
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Misinterpretation of chest x-rays
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered.
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to use a lead anatomical marker when taking chest x-rays
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered.
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 by clinicians to identify incorrectly labelled chest x-rays
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered.
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 both chest x-rays
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered .
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Incorrect labelling of chest x-rays
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled , and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered.
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain.
” Open source report
Concerns raised 10 Insufficiently thorough and incisive investigation of safety incidents View source Failure to ensure all 111 service providers understand the limitations of the BT service for disclosing data sensitive information View source Delays in referring cases and dispatching ambulances after failure to obtain caller location information View source Failure to ensure that life-saving procedural information reaches all staff involved in call handling View source Absence of a clear and robust policy and practice for addressing caller-location problems View source Delays in providing substantive safety advice to control room staff after potential systemic failures are identified View source Failure to ensure 111 and ambulance dispatch staff know and are trained in procedures for locating seriously ill patients with incomplete whereabouts information View source Absence of specific training on caller-location and dispatch procedures View source Failure to provide BT with complete information when requesting release of a caller's address View source Failure of ambulance service protocols to address caller-location and dispatch problems View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Gary William Million · 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
Gary William Million telephoned 111 on 23 November 2013 but could not provide clear information about his location and then became silent. There was a prolonged delay in locating his address, including an incorrect address being given to the ambulance, and the crew attended the correct address at 01:10. The concerns included inadequate procedures and training for locating potentially seriously ill callers, communication issues with BT, weaknesses in the investigation and insufficiently robust follow-up procedures.
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 Insufficiently thorough and incisive investigation of safety incidents
Wider context from the report “4. A detailed investigation that was undertaken by North East Ambulance Trust is upon closer examination, in places lacking depth and incisiveness .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 all 111 service providers understand the limitations of the BT service for disclosing data sensitive information
Wider context from the report “2. BT’s evidence was that they have given further advice and information to blue light service providers (namely Fire, Police, Ambulance, Coastguard) but as they do not know of the identity of all 111 providers it is very possible that other 111 providers may not understand the limitations of the BT service for disclosing data sensitive information and therefore, so that this issue can be considered and lessons learnt therefrom the Department of Health ought to consider sharing this information with all other 111 service providers throughout the country to reduce the risk of similar fatalities in the future. A copy of the full Regulation 28 report addressed to North East Ambulance Service Trust is attached.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 referring cases and dispatching ambulances after failure to obtain caller location information
Wider context from the report “1. Once the 111 operator had failed to obtain detailed information about the callers location, there was a delay of some minutes before referring the matter to the Ambulance Trust and for the dispatch of an ambulance .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that life-saving procedural information reaches all staff involved in call handling
Wider context from the report “7. Upon receipt from BT of an email in February 2014 in which BT endeavoured to address the issues raised by this death, the North East Ambulance Service Trust, copied the email to senior managers and other staff (though it is not known who exactly) to advise them of the change of procedure but other than merely forwarding the email the North East Ambulance Service Trust did not take any steps to try and ensure that this potentially life saving information was known by all people who were involved in the call handling process . No specific training on this important issue has been carried out as at the date hereof and none was planned.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 clear and robust policy and practice for addressing caller-location problems
Wider context from the report “8. The response to the incident by the Trust appears perfunctory and now, eight months after the death of the deceased, notwithstanding the changes made to practice and procedure by the North East Ambulance Service Trust it is clear that a clear and robust policy and practice to address this issue is not in 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 Delays in providing substantive safety advice to control room staff after potential systemic failures are identified
Wider context from the report “6. The deceased died in November 2013 and within a day or two of the death being reported, it was clear that the circumstances of the death highlighted serious potential systemic failures and yet, no substantive further advice was given to control room staff until February 2014 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 111 and ambulance dispatch staff know and are trained in procedures for locating seriously ill patients with incomplete whereabouts information
Wider context from the report “2. No 111/ambulance dispatch staff knew of or had been trained about the correct procedure to be adopted when trying to locate a potentially seriously ill patient when they had incomplete information as to that persons whereabouts. In short, they did not know how to obtain the callers address . Despite the considerable and well intentioned efforts of a number of people working in the call centre, these individuals failed to locate the deceased’s home address and as a result there was an inordinate delay before the ambulance crew were able to attend the deceased’s property.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 specific training on caller-location and dispatch procedures
Wider context from the report “7. Upon receipt from BT of an email in February 2014 in which BT endeavoured to address the issues raised by this death, the North East Ambulance Service Trust, copied the email to senior managers and other staff (though it is not known who exactly) to advise them of the change of procedure but other than merely forwarding the email the North East Ambulance Service Trust did not take any steps to try and ensure that this potentially life saving information was known by all people who were involved in the call handling process. No specific training on this important issue has been carried out as at the date hereof and none was planned .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 BT with complete information when requesting release of a caller's address
Wider context from the report “3. When the ambulance service duty manager spoke to BT, that individual did not fully explain the nature and reason for the enquiry with the result that the BT operator was not seized of all relevant information with which he could make a fully reasoned decision as to whether to exercise his discretion or not to release the deceased’s home address to the caller.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 service protocols to address caller-location and dispatch problems
Wider context from the report “5. New revised North East Ambulance Service Trust protocols which are undated, and which were produced to the Senior Coroner only on the morning of the Inquest being resumed, do not deal with the problems identified in this case even though they were designed to address them.
” Open source report
25 Jul 2014 Nathan James Healer · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 2 Failure to provide timely blood glucose testing for newborns View source Lack of finalized and current guidance on newborn blood glucose testing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nathan James Healer · 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
Nathan James Healer was born on 03/02/2014 and died on 05/02/2014 after developing signs including low temperature, poor feeding and jittering arms. His first blood glucose measurement, taken almost five hours after birth, was 0.2 mmol/L. The principal concern was that the severity of his condition was not appreciated and he was not given a more timely blood glucose test, in the context of existing clinical 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 Failure to provide timely blood glucose testing for newborns
Wider context from the report “I was made aware of :-
a) the 2008 NICE Clinical Guidance 63 “Diabetes in Pregnancy” which in essence recommended a pre 2nd Feed Blood Glucose test at between 2-4 hours;
b) the hospital Guidance for “Hypothermia in the newborn Infant” 2014;
c) the hospital Guidance for “Prevention, detection and management of hypoglycaemia in the newborn 2012 (Blood glucose test at around 4 hours).
Although the severity of Nathans’s condition was not appreciated and he was not given the opportunity of a more timely blood glucose test I heard evidence that although new guidance from NICE is in contemplation it has not yet been finalised.
If that is the case then it would be helpful to know what stage this is at and whether any steps can be taken to expedite it’s production.
If no new guidance is in contemplation then it may be an opportune moment to revisit the guidance in any event.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 finalized and current guidance on newborn blood glucose testing
Wider context from the report “I was made aware of :-
a) the 2008 NICE Clinical Guidance 63 “Diabetes in Pregnancy” which in essence recommended a pre 2nd Feed Blood Glucose test at between 2-4 hours;
b) the hospital Guidance for “Hypothermia in the newborn Infant” 2014;
c) the hospital Guidance for “Prevention, detection and management of hypoglycaemia in the newborn 2012 (Blood glucose test at around 4 hours).
Although the severity of Nathans’s condition was not appreciated and he was not given the opportunity of a more timely blood glucose test I heard evidence that although new guidance from NICE is in contemplation it has not yet been finalised .
If that is the case then it would be helpful to know what stage this is at and whether any steps can be taken to expedite it’s production.
If no new guidance is in contemplation then it may be an opportune moment to revisit the guidance in any event .
” 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 Further questions about the guidance review should be directed to NICE, an independent body.
Verbatim wording from the response “Given the imminence of the new guidance, advice from Departmental policy officials is that there is no scope for this process to be expedited. However, as NICE is an independent body, I advise you contact it directly with any further questions you may have about the review of this guidance.” Source location 2014-0343-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 imminent NICE guidance review cannot be expedited.
Verbatim wording from the response “Given the imminence of the new guidance, advice from Departmental policy officials is that there is no scope for this process to be expedited. However, as NICE is an independent body, I advise you contact it directly with any further questions you may have about the review of this guidance.” Source location 2014-0343-Response-by-Department-of-Health
Open published response
25 Jul 2014 Donna Kirkland · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 4 Lack of staff awareness of the alcohol content and ingestion potential of alcohol based hand sanitising gels View source Patients’ permitted retention of cups and containers of alcohol based hand sanitising gels in their rooms View source Patients’ permitted decanting of alcohol based hand sanitising gels into cups and other containers View source Patients’ unlimited access to alcohol based hand sanitising gels View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Donna Kirkland · 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
Donna Kirkland was found deceased in her bed on 22 August 2013 after ingesting alcohol-based hand sanitising gel while detained on a mental health ward. The principal concerns were patients’ unrestricted access to the gel, permission to decant and keep it in rooms, and insufficient staff awareness of its alcohol content and potential ingestion.
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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 staff awareness of the alcohol content and ingestion potential of alcohol based hand sanitising gels
Wider context from the report “(1) Patients having unlimited access to alcohol based hand sanitising gels;
(2) Patients being permitted to decant alcohol based hand sanitising gels into cups and other such containers;
(3) Patients being permitted to keep cups and containers of alcohol based hand sanitising gels in their rooms;
(4) Lack of awareness amongst staff of alcohol content of alcohol based hand sanitising gels and the potential for such gels to be ingested .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Patients’ permitted retention of cups and containers of alcohol based hand sanitising gels in their rooms
Wider context from the report “(1) Patients having unlimited access to alcohol based hand sanitising gels;
(2) Patients being permitted to decant alcohol based hand sanitising gels into cups and other such containers;
(3) Patients being permitted to keep cups and containers of alcohol based hand sanitising gels in their rooms ;
(4) Lack of awareness amongst staff of alcohol content of alcohol based hand sanitising gels and the potential for such gels to be ingested.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Patients’ permitted decanting of alcohol based hand sanitising gels into cups and other containers
Wider context from the report “(1) Patients having unlimited access to alcohol based hand sanitising gels;
(2) Patients being permitted to decant alcohol based hand sanitising gels into cups and other such containers ;
(3) Patients being permitted to keep cups and containers of alcohol based hand sanitising gels in their rooms;
(4) Lack of awareness amongst staff of alcohol content of alcohol based hand sanitising gels and the potential for such gels to be ingested.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Patients’ unlimited access to alcohol based hand sanitising gels
Wider context from the report “(1) Patients having unlimited access to alcohol based hand sanitising gels ;
(2) Patients being permitted to decant alcohol based hand sanitising gels into cups and other such containers;
(3) Patients being permitted to keep cups and containers of alcohol based hand sanitising gels in their rooms;
(4) Lack of awareness amongst staff of alcohol content of alcohol based hand sanitising gels and the potential for such gels to be ingested.
” Open source report
Concerns raised 3 Failure to inform family members about available support information and support for themselves View source Failure to engage family members in support when information sharing is declined View source Failure to verify the accuracy and interpretation of information recorded from family members View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joshua Lewis BROWN · 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
Joshua Lewis BROWN died on 13 June 2011 after climbing over railings at the edge of cliffs at Louisa Bay and dropping forward from the cliff. The report identified concerns about limited information-sharing and engagement between the Community Health Team and Mr Brown’s family, including the absence of a process for family members to check the accuracy of information recorded about them. It also noted that the family was not made aware of available support and information about how best to support Mr Brown and themselves.
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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 inform family members about available support information and support for themselves
Wider context from the report “(1) The evidence was that Mr Brown lived with his parents who were therefore his primary support outside the Community Health Team but were not strictly speaking his carers and therefore were not formally able to be involved as such by the Community Team when Mr Brown did not wish information about him to be shared. They therefore did not receive information that might have alerted them to periods when he was particularly vulnerable and when they might have had information that would have been of assistance to the Team in caring for Mr Brown.
(2) The evidence also demonstrated that it was not the practice of the Team to show family members what notes had been made by the Team of information shared with them by family members, with the consequence that inaccuracies or misunderstandings may have arisen in some notes, and there was no provision for those notes to be signed as accurate by the relevant family members.
(3) The family members were not made aware of ways in which they could obtain through the Kent and Medway NHS Social Care and Partnership Trust (of which the Team was a part) more information about how they might best support Mr Brown and themselves receive support.
(4) In general, the evidence showed limitations on the possibilities for engagement by the Team with family members and by family members with the Team, particularly when Mr Brown did not wish information about him to be shared and this worked to his disadvantage. There was, however, evidence of some improvement having already been made by the Trust in this respect. When engagement was possible, the absence of a system whereby a person giving information to the Team would check that that information had been correctly noted and interpreted by the Team posed obvious risks for anyone under the care of the Team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to engage family members in support when information sharing is declined
Wider context from the report “(1) The evidence was that Mr Brown lived with his parents who were therefore his primary support outside the Community Health Team but were not strictly speaking his carers and therefore were not formally able to be involved as such by the Community Team when Mr Brown did not wish information about him to be shared . They therefore did not receive information that might have alerted them to periods when he was particularly vulnerable and when they might have had information that would have been of assistance to the Team in caring for Mr Brown.
(2) The evidence also demonstrated that it was not the practice of the Team to show family members what notes had been made by the Team of information shared with them by family members, with the consequence that inaccuracies or misunderstandings may have arisen in some notes, and there was no provision for those notes to be signed as accurate by the relevant family members.
(3) The family members were not made aware of ways in which they could obtain through the Kent and Medway NHS Social Care and Partnership Trust (of which the Team was a part) more information about how they might best support Mr Brown and themselves receive support.
(4) In general, the evidence showed limitations on the possibilities for engagement by the Team with family members and by family members with the Team, particularly when Mr Brown did not wish information about him to be shared and this worked to his disadvantage. There was, however, evidence of some improvement having already been made by the Trust in this respect. When engagement was possible, the absence of a system whereby a person giving information to the Team would check that that information had been correctly noted and interpreted by the Team posed obvious risks for anyone under the care of the Team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 verify the accuracy and interpretation of information recorded from family members
Wider context from the report “(1) The evidence was that Mr Brown lived with his parents who were therefore his primary support outside the Community Health Team but were not strictly speaking his carers and therefore were not formally able to be involved as such by the Community Team when Mr Brown did not wish information about him to be shared. They therefore did not receive information that might have alerted them to periods when he was particularly vulnerable and when they might have had information that would have been of assistance to the Team in caring for Mr Brown.
(2) The evidence also demonstrated that it was not the practice of the Team to show family members what notes had been made by the Team of information shared with them by family members , with the consequence that inaccuracies or misunderstandings may have arisen in some notes, and there was no provision for those notes to be signed as accurate by the relevant family members .
(3) The family members were not made aware of ways in which they could obtain through the Kent and Medway NHS Social Care and Partnership Trust (of which the Team was a part) more information about how they might best support Mr Brown and themselves receive support.
(4) In general, the evidence showed limitations on the possibilities for engagement by the Team with family members and by family members with the Team, particularly when Mr Brown did not wish information about him to be shared and this worked to his disadvantage. There was, however, evidence of some improvement having already been made by the Trust in this respect. When engagement was possible, the absence of a system whereby a person giving information to the Team would check that that information had been correctly noted and interpreted by the Team posed obvious risks for anyone under the care of the Team.
” 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 Facilitate and publish a confidentiality, information-sharing and suicide-prevention consensus statement alongside the first annual suicide-prevention strategy report.
Verbatim wording from the response “The Department has therefore facilitated a consensus statement on confidentiality, Information sharing and suicide prevention: consensus statement, which was published in January 2014 alongside the first annual report on the suicide prevention strategy.” Source location 2014-0289-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 Clinicians cannot disclose confidential information when a capable patient at suicide risk refuses consent and disclosure is not otherwise warranted.
Verbatim wording from the response “Current legislation provides that, where a clinician believes that a patient is at risk of suicide, and that patient refuses to provide consent for information to be shared with family members or any other third party, and, in the judgement of the clinician, the patient has full mental capacity to understand the risks, then disclosure of that patient’s confidential information is not warranted.” Source location 2014-0289-Response-by-Department-of-Health
Open published response
Concerns raised 3 Lack of post-mortem analysis of medical devices in unexplained deaths View source Inconsistent issuing of FSNs to appropriate NHS Trust recipients View source Delays in Medtronic providing safety data on request 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
Shayla Anne Walmsley · 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
Shayla Anne Walmsley was found deceased at her home on 9 May 2013; she had diabetes and used a Medtronic insulin pump. The cause of death remained unascertained, and the report raised concerns about delays in providing safety data, inconsistent distribution of Field Safety Notices, and failure to analyse the medical device during the post-mortem investigation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of post-mortem analysis of medical devices in unexplained deaths
Wider context from the report “(3) Non-analysis of medical devices at post mortem - I am concerned that future investigations into the deaths of medical device users could be impaired by the lack of analysis of medical devices at post mortem . It is clear that these devices are increasingly being used by patients and, if death is unexplained in such a patient, appropriate analysis should be considered . As such, I believe that it is necessary to emphasise, to those involved in death investigation, the potential importance of device analysis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 issuing of FSNs to appropriate NHS Trust recipients
Wider context from the report “(2) Inconsistency in issuing FSNs - I am concerned that the apparently ad hoc nature by which FSNs are issued applies inappropriate individuals within NHS Trusts being aware of safety concerns and that this could result in future deaths. It is clear the CAS distributes MDAs to NHS Trust governance departments in a reliable manner. I believe that consideration should be made as to whether CAS could be used also to distribute FSNs.
I heard evidence from the governance department representative that this would not lead to ‘alert fatigue’ (where receipt of numerous alerts results in less attention being paid to them). This is because governance departments should be receiving these FSNs in any case and taking steps to distribute as appropriate. I heard concerns from the MHRA that this view may not be shared by all governance departments but, in my judgement, there should be consideration of the use of CAS for FSN distribution.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Medtronic providing safety data on request
Wider context from the report “(1) Interval to availability of Medtronic data - I am concerned that the investigatory role of non-US regulators could be hampered by the timescale within which Medtronic can provide data on request . Given the potential consequences of a delay in production of this safety data , I believe that future deaths could result and that this warrants consideration by Medtronic.
” Open source report
Concerns raised 1 Failure of hospital staff to refer discharging patients to community psychological services 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
Farres Ikken · 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
Farres Ikken was arrested after stating that he wanted to kill himself, assessed by mental health services, and discharged for follow-up by his GP. Shortly after leaving the hospital, he hanged himself in the hospital grounds; the substantive concern was that hospital staff could not directly refer him to community psychological services on discharge.
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 hospital staff to refer discharging patients to community psychological services
Wider context from the report “That staff at the hospital could not themselves, on discharge, refer Mr Ikken to community psychological services .
” Open source report
Concerns raised 2 Failure to hold effective multidisciplinary meetings View source Excessive Home Treatment Team caseloads View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Henry Marsh · 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
Henry Marsh had multiple diagnoses and was under the care of the Home Treatment Team when he failed to attend a psychology appointment and was found unresponsive at home. The principal concern was that the Home Treatment Team had too many patients to manage effectively, making multidisciplinary meetings difficult; the inquest recorded suicide and polydrug intoxication as the medical cause of 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 hold effective multidisciplinary meetings
Wider context from the report “The numbers of patients that the Home Treatment Team have under their care were too many and there were difficulties in holding effective multi – disciplinary meetings when carrying such a large caseload.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Excessive Home Treatment Team caseloads
Wider context from the report “The numbers of patients that the Home Treatment Team have under their care were too many and there were difficulties in holding effective multi – disciplinary meetings when carrying such a large caseload .
” 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 Responsibility for resourcing Home Treatment Teams rests with local Clinical Commissioning Groups.
Verbatim wording from the response “The inquest concluded that Mr Marsh committed suicide whilst under the care of the local Home Treatment Team. You are concerned that the team could not function effectively with its current caseload.” Source location 2014-0306-Response-by-Department-of-Health
Open published response
30 Jun 2014 William Reid · Prevention of Future Deaths report Cumbria (North & West)
View report summary
Concerns raised 4 Delays in recognising deteriorating condition View source Failure to inform the GP of hospital discharge View source Delays in admission to hospital View source Failure to inform the GP of hospital admission 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
William Reid · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William Reid was found deceased at his home on 24 July 2013, having lived alone and with a delay in the discovery of his death. Concerns included delayed recognition of his deteriorating condition, delayed hospital admission, and failure to inform his GP about his hospital admission and discharge.
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 recognising deteriorating condition
Wider context from the report “His admission to hospital in 2013 was not known to his GP. The deceased was discharged from hospital without his GP being informed. There was a delay in the recognition of his deteriorating condition and in his subsequent admission to hospital. The risk is that future deaths will occur unless action is taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the GP of hospital discharge
Wider context from the report “His admission to hospital in 2013 was not known to his GP. The deceased was discharged from hospital without his GP being informed. There was a delay in the recognition of his deteriorating condition and in his subsequent admission to hospital. The risk is that future deaths will occur unless action is taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 admission to hospital
Wider context from the report “His admission to hospital in 2013 was not known to his GP. The deceased was discharged from hospital without his GP being informed. There was a delay in the recognition of his deteriorating condition and in his subsequent admission to hospital. The risk is that future deaths will occur unless action is taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the GP of hospital admission
Wider context from the report “His admission to hospital in 2013 was not known to his GP. The deceased was discharged from hospital without his GP being informed. There was a delay in the recognition of his deteriorating condition and in his subsequent admission to hospital. The risk is that future deaths will occur unless action is taken.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the Information Strategy establishing a framework for recording and securely sharing health and care information using consistent standards.
Verbatim wording from the response “In addition, the Governments Information Strategy “The Power of Information: Putting all of us in control of the health and care information we need” was published in May 2012. A copy can be found on the GOV.UK website via the following link: The Power of Information. The Strategy sets a ten-year framework for transforming information for health and care. It aims to harness information and new technologies to achieve higher quality care and improve outcomes for patients and service users.” Source location 2014-0288-Response-by-Department-of-Health
Open published response
27 Jun 2014 ASHLEY CORIN DE WINTER PONSONBY · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 3 Lack of staff training in recognising and dealing with physical harm and risks from illicit substance use in wards with dual diagnosis patients View source Lack of a coherent and mutually understood Mental Health Trust and Police policy on involvement in illegal activity View source Failure to use incident reporting and risk-register procedures to identify drug supply or consumption 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
ASHLEY CORIN DE WINTER PONSONBY · 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
Ashley Ponsonby was a detained dual-diagnosis patient who died after injecting illicit drugs on a psychiatric ward. The inquest found amphetamine and paramethoxyamphetamine toxicity as the cause of death, with contributing factors including poor communication, inadequate observations and escalation, failure to recognise toxicity and deterioration, inadequate control of access to illicit drugs, insufficient staff training, and an inadequate emergency response. Concerns included the absence of staff training in managing physical risks from illicit substances, failures to use incident-reporting and risk-register procedures, and the lack of a coherent policy governing cooperation between the Mental Health Trust and police regarding illegal activity.
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 training in recognising and dealing with physical harm and risks from illicit substance use in wards with dual diagnosis patients
Wider context from the report “1. It is a matter of concern that any ward could be set up and operated involving the inherent risks of drug misuse by dual diagnosis patients without the staff having any training in recognising and dealing with the physical harm and risks arising from the use of illicit substances . The evidence from the independent psychiatrist was that this was an essential ingredient. Consequently, in rehabilitation wards or those with dual diagnosis patients where there is a risk of continuing drug misuse , the concern which arose was that without this, there was a risk of a future death arising. This has implications locally for the Trust, regionally and on a national basis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a coherent and mutually understood Mental Health Trust and Police policy on involvement in illegal activity
Wider context from the report “3. There was a concern that a lack of a coherent and mutually understood policy between the Mental Health Trust and the Police as to when they would become involved in illegal activity meant that neither the patients nor the staff had clarity on the position . Just because patients have mental disorder, does not absolve them of all legal responsibilities and indeed understanding and facing possible criminal consequences may be important in their overall clinical management and for the administration of justice. It was suggested that this was being considered by Greater Manchester Police and the local Police and Crime Commissioner, but no policy had yet been finalised . Once again, this has local, regional and national implications, and that the concern is without such policies being formulated and implemented, there is a continuing risk of future deaths which could be prevented.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to use incident reporting and risk-register procedures to identify drug supply or consumption
Wider context from the report “2. There is a concern that the failure to use the Datix and Trust incident reporting policy, as well as the risk register (or other similar procedures available to other Mental Health Trusts), to identify the problem of drug supply and/or consumption , if unremedied may lead to a future death. It is a concern both locally for the Trust, regionally and nationally, that such procedures should be appropriately used so as to prevent a future death.
” Open source report
Concerns raised 6 Delays in initiating investigative procedures View source Unavailability of private investigative procedures View source Inconsistent timing and pathways for investigative procedures in differential diagnosis including ARVC View source Delays in multidisciplinary review of syncope investigations View source Inconsistent advice to fit young athletes about future exercise View source Inconsistent national management of syncope in young athletes 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
Peter John Hinchliffe · 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 John Hinchliffe, a fit 33-year-old man, died after collapsing while cycling on 11 September 2010; the inquest concluded that the cause of death was arrhythmogenic right ventricular cardiomyopathy, which was undiagnosed and untreated. The principal concerns were delays and differing approaches in investigating syncope, including delays in transferring investigations to the NHS, and inconsistent advice about exercise for young athletes in a recognised red-flag situation.
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 initiating investigative procedures
Wider context from the report “(2) In the private sector there was delay initiating investigative procedures after the consultation on 29th June 2010.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 private investigative procedures
Wider context from the report “(1) All investigative procedures could not be undertaken privately and transfer to the National Health Service was necessary to complete investigations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 timing and pathways for investigative procedures in differential diagnosis including ARVC
Wider context from the report “(4) Evidence revealed significant differences in the times and routes taken to undertake investigative procedures in cases where there is a differential diagnosis including ARVC.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 multidisciplinary review of syncope investigations
Wider context from the report “(3) Although Peter John Hinchliffe died approximately two weeks after transfer into the NHS system no further progress would have been made until after the MDT meeting in early October some 4 – 5 months after the incident of syncope.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 advice to fit young athletes about future exercise
Wider context from the report “(5) The evidence revealed inconsistencies of approach in advice to fit young athletes as to future exercise in what was generally acknowledged to be a ‘red flag’ situation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistent national management of syncope in young athletes
Wider context from the report “(6) Whilst there has been greater awareness since 2010 both locally and nationally of the need for timely and appropriate management of syncope in young athletes the approach to the problem does not appear to be consistent nationally and there is a continuing need to emphasise and act on this issue.
” Open source report
Concerns raised 5 Window restraint locks being easily defeated with scissors View source Lack of proper systems for restricting access to window restraint keys View source Failure to ensure that CQC inspectors are properly aware of relevant Department of Health alerts View source Window restraints appearing secure despite not being locked View source Lack of a system for passing on CQC knowledge of misleading window restraint lock conditions View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Miss Lucy Moffatt · 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
Miss Lucy Moffatt, who was experiencing an acute phase of paranoid schizophrenia, fell or jumped from the second-floor window of her room at a Crisis House in Sheffield after being admitted on 9 July 2013. The report raised concerns that the window restraint could appear secure without being locked, could be defeated with scissors, and was not supported by sufficiently robust monitoring and key-control systems. It also identified concerns about CQC inspectors not being made properly aware of relevant Department of Health guidance and information about the restraint’s limitations.
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 Window restraint locks being easily defeated with scissors
Wider context from the report “(2) The lock on the window restraint could easily be defeated with a pair of scissors and this may be the case on many similar devices .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 proper systems for restricting access to window restraint keys
Wider context from the report “(3) Although the provider in question has now taken appropriate action, it may well be that many other such establishments have no proper system of window restraint key restriction .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that CQC inspectors are properly aware of relevant Department of Health alerts
Wider context from the report “(4) The CQC Inspectors had not apparently been made properly aware of the Dept of Health Alert on a matter that they were expected to check .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Window restraints appearing secure despite not being locked
Wider context from the report “(1) That the type of window restraint in question can appear secure to a 'pulling and tugging' check when it is not actually locked . This can mislead those unaware of the issue .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for passing on CQC knowledge of misleading window restraint lock conditions
Wider context from the report “(5) There is no system to ensure that CQC knowledge of a potentially misleading situation with the window restraint lock was passed on , albeit in the belief that the restraint would be locked and that residents would be low risk.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discussed the report with the CQC and considered how to ensure Safety Alerts reach appropriate teams.
Verbatim wording from the response “I also note your concerns about communication between the Department of Health and the CQC. Officials at my Department have discussed your report with the CQC and considered how the CQC can ensure that these alerts are reaching the appropriate teams.” Source location 2014-0261-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Providers, rather than the Department or CQC, are responsible for managing patient safety, actioning alerts, and selecting suitable window restrictors.
Verbatim wording from the response “The CQC have confirmed that neither the registration assessor nor the inspector in this case were specifically aware of the Department of Health alert concerning the strength of window restraints. However, under the current statutory and regulatory framework of the primary responsibility for managing patient safety and ensuring that such alerts are actioned lies with the provider.” Source location 2014-0261-Response-by-Department-of-Health
Open published response
9 Jun 2014 Daniel Joseph McCallum Keane · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Failure to respond to an urgent clinical alert about unsafe self-management of insulin View source Inadequate clinical record keeping View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Daniel Joseph McCallum Keane · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel Keane was found dead at home after a period in which he had difficulty managing his Type 1 diabetes and was left without active support apart from his family. The cause of death was recorded as ketoacidosis. The reported concerns included a lack of leadership and coordination, no clear post-discharge care plan, ineffective multidisciplinary meetings, and uncertainty about the GP’s role, including the prescribing of citalopram and failure to respond to concerns about Daniel’s wellbeing.
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 respond to an urgent clinical alert about unsafe self-management of insulin
Wider context from the report “████████ was called to give evidence at the Inquest. He accepted in the course of his evidence that his record keeping was inadequate. He could not say from either his records or his recollection who had arranged for diabetic medication or citalopram to be prescribed on 29th September 2010.
████████ had no recollection or contemporaneous record of a telephone conversation with a neuropsychologist called ████████ on 8th November 2010 in which she said she alerted ████████ to Daniel Keane’s situation, which she described to him and indicated it was very worrying. ████████ asked him to make an urgent referral to the district nurses as she was concerned he was not reliable in managing his insulin himself. ████████ said he could not refer to the district nurses. Despite having been put on alert in this telephone conversation ████████ took no action.
At this time ████████ was in possession of various reports including a Multi-Disciplinary Team Discharge Summary dated 2nd September 2010 that concluded Daniel Keane was at extreme risk to himself and was not a safe option to live by himself without supervision.
2. An investigation of the circumstances in which citalopram was prescribed on 29th September 2010 to establish who deemed this medication necessary, what features of his presentation justified this medication and the follow up action envisaged.
3. An investigation into ████████'s lack of response to the telephone conversation with ████████ on 8th November 2010.
4. Consideration of the role of GP’s generally in relation to the management of Type 1 diabetic patients 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 Inadequate clinical record keeping
Wider context from the report “████████ was called to give evidence at the Inquest. He accepted in the course of his evidence that his record keeping was inadequate. He could not say from either his records or his recollection who had arranged for diabetic medication or citalopram to be prescribed on 29th September 2010.
████████ had no recollection or contemporaneous record of a telephone conversation with a neuropsychologist called ████████ on 8th November 2010 in which she said she alerted ████████ to Daniel Keane’s situation, which she described to him and indicated it was very worrying. ████████ asked him to make an urgent referral to the district nurses as she was concerned he was not reliable in managing his insulin himself. ████████ said he could not refer to the district nurses. Despite having been put on alert in this telephone conversation ████████ took no action.
At this time ████████ was in possession of various reports including a Multi-Disciplinary Team Discharge Summary dated 2nd September 2010 that concluded Daniel Keane was at extreme risk to himself and was not a safe option to live by himself without supervision.
2. An investigation of the circumstances in which citalopram was prescribed on 29th September 2010 to establish who deemed this medication necessary, what features of his presentation justified this medication and the follow up action envisaged.
3. An investigation into ████████'s lack of response to the telephone conversation with ████████ on 8th November 2010.
4. Consideration of the role of GP’s generally in relation to the management of Type 1 diabetic patients in the community.
” 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 Concerns about the practice’s record keeping, prescribing and response should be addressed by the GMC and CQC, which can take action where warranted.
Verbatim wording from the response “I consider that the first three concerns, relating to ████████ should be raised with the General Medical Council (GMC) and the Care Quality Commission (CQC). To this end, my officials contacted your office on 12 June to advise that these actions would be most appropriately addressed by the GMC and CQC. We suggested that you write to both of these organisations for their separate responses to these issues. These organisations have the power to take action where warranted.” Source location 2014-0260-Response-by-Department-of-Health
Open published response
6 Jun 2014 Katie Louise Davies · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Failure of hospital bleeper systems to provide coverage throughout all hospital precincts View source Lack of policies and guidelines for the assessment, management and treatment of cerebral venous thrombosis View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Katie Louise Davies · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Katie Louise Davies died in hospital on 26 December 2012 after developing Cerebral Venous Sinus Thrombosis and suffering a cardiac arrest. The report raised concerns about blind spots in hospital bleeper systems delaying clinicians’ responses and about differing policies for managing and transferring patients with Cerebral Venous Thrombosis to regional neuroscience centres.
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 hospital bleeper systems to provide coverage throughout all hospital precincts
Wider context from the report “In the course of investigations at the Royal Albert Edward Infirmary, Wigan, in relation to the failure of Doctors to respond to contact by use of the internal bleeper system during the deceased’s admission, it was discovered that there were two blind or blank spots within the precincts of the Hospital, where bleepers could not be activated . The blind or blank spots were previously unknown but were rectified so that bleepers can now be activated within all precincts of the Hospital.
Evidence was given that it is believed that similar problems may exist at other Hospitals in the United Kingdom and Hospitals may be unaware of the existence of blind or blank spots within the Hospital .
I have concerns that if blind or blank spots exist within Hospitals that there would be a delay in the response of Clinicians to emergencies and patients requiring urgent treatment and in my opinion there is a risk that future deaths will occur unless action is taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of policies and guidelines for the assessment, management and treatment of cerebral venous thrombosis
Wider context from the report “However, evidence was given that in parts of the United Kingdom, and in particular in London and Cambridge, the management of patients diagnosed with Cerebral Venous Sinus Thrombosis involved the transfer of patients from a District General Hospital to a Regional Neuroscience Centre, as soon as reasonably practicable after a confirmed diagnosis, to allow the patient to receive treatment in a Regional Centre where Specialties and Sub-Specialties exist, including Consultant Neurosurgeons, Consultant Neurologists and Consultant Neuroradiologists together with appropriate resources and facilities available on a 24 hour a day 365 day year basis.
The evidence confirmed that the treatment of Venous Thrombosis or Venous Stroke is different to the treatment of Cerebral Artery Thrombosis or Cerebral Stroke. The Experts agreed that the treatment of Cerebral Venous Sinus Thrombosis requires initial anticoagulation treatment and monitoring with regular neurological examinations and neurological observations and, where there is a significant deterioration, invasive procedures should be considered including Thrombolysis, Thrombectomy or Clot Extraction and Craniectomy, which can only be carried out at a Regional Neuroscience Centre.
iii. Following the deceased’s death, a full investigation in relation to the treatment of patients with Cerebral Venous Sinus Thrombosis was conducted by ████████ Consultant Neurologist and Clinical Director of Medical Neurosciences at Salford Royal Hospital who, together with ████████ Consultant Neurologist Specialising in Cerebrovascular Diseases has produced a policy and guidelines for the assessment and management of adult patients with Cerebral Venous Thrombosis in Greater Manchester, a copy of which is attached hereto.
The document is extensive and refers to the expectation that all patients suffering Cerebral Venous Thrombosis will be transferred from the District General Hospital to the Regional Medical Neuroscience Centre after a confirmed diagnosis of the condition to enable the patient to have the benefit of the Specialties, resources, facilities and invasive procedures only available at the Regional Centre.
The evidence at the Inquest indicated that policies and guidelines similar to those produced by ████████ do not exist in many parts of the United Kingdom . In my opinion, there is a risk that future deaths will occur unless action is taken to review the policy and guidelines for the assessment, management and treatment of patients suffering Cerebral Venous Thrombosis in all parts of the United Kingdom .
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations