Concerns raised 7 Sale of online drugs in doses and quantities larger than ordinarily prescribed View source Failure to establish the suitability of online drug purchasers View source Failure to assess online drug suitability against the purchaser’s medical history View source Lack of regulation of online supply of powerful drugs View source Failure to inform the purchaser’s GP practice of online drug purchases View source Lack of safety and quality control for drugs supplied online View source Failure to control duplicate, excessive or frequent online drug purchases View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nigel Walter DIXON · 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
Nigel Walter Dixon, a 64-year-old man who lived alone, was found dead at home on 13 February 2023 after being unable to be roused. His cause of death was morphine and Zopiclone toxicity. Concerns included his access to morphine after hospital discharge and the online supply of large quantities and dosages of Zopiclone without adequate checks, communication with his GP, or safeguards.
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 Sale of online drugs in doses and quantities larger than ordinarily prescribed
Wider context from the report “Mr Dixon was able to purchase ████████ Zopiclone tablets ████████ online from a company ████████
The GP who gave evidence at the inquest described this as a “huge” amount of the drug. She confirmed that she would only prescribe 28 days’ worth of ████████ tablets in one go (████████ Mr Dixon was able to purchase). The selling of tablets which are a larger dose and in a much larger quantity than would ordinarily be prescribed online risks an accidental or intentional overdose of the drug and also risks the drug being sold on the black market.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to establish the suitability of online drug purchasers
Wider context from the report “It is gravely concerning that powerful drugs are available online so freely and in such large quantities, with little to nothing in the way of checks and balances around who the drugs are being sold to. There seems to be no regulation of the supply of these drugs and that seems to me to inevitably put the lives of vulnerable people at risk. In this case there was no communication with Mr Dixon’s GP and I would imagine there is no way for these online companies to check whether their customers are placing duplicate orders with other websites, there seems therefore to be a situation where one could purchase almost limitless amounts of these drugs with no checks or balances at all. There seems to be no system for establishing the suitability of the purchaser , nor a system to limit the amount or frequency of medication being purchased.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 online drug suitability against the purchaser’s medical history
Wider context from the report “The evidence of the GP was that the company who supplied these drugs to Mr Dixon did not contact the GP Practice to discuss their suitability or check Mr Dixon’s medical history , nor did they inform the GP’s Practice of the purchase.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of regulation of online supply of powerful drugs
Wider context from the report “It is gravely concerning that powerful drugs are available online so freely and in such large quantities, with little to nothing in the way of checks and balances around who the drugs are being sold to. There seems to be no regulation of the supply of these drugs and that seems to me to inevitably put the lives of vulnerable people at risk. In this case there was no communication with Mr Dixon’s GP and I would imagine there is no way for these online companies to check whether their customers are placing duplicate orders with other websites, there seems therefore to be a situation where one could purchase almost limitless amounts of these drugs with no checks or balances at all. There seems to be no system for establishing the suitability of the purchaser, nor a system to limit the amount or frequency of medication being purchased.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 purchaser’s GP practice of online drug purchases
Wider context from the report “The evidence of the GP was that the company who supplied these drugs to Mr Dixon did not contact the GP Practice to discuss their suitability or check Mr Dixon’s medical history, nor did they inform the GP’s Practice of the purchase .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 safety and quality control for drugs supplied online
Wider context from the report “The evidence of the GP is it is hard to prescribe safely to people who are supplementing their prescription drugs with online purchases. Further, she raised concerns about the safety and quality control of the drugs being supplied .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to control duplicate, excessive or frequent online drug purchases
Wider context from the report “It is gravely concerning that powerful drugs are available online so freely and in such large quantities, with little to nothing in the way of checks and balances around who the drugs are being sold to. There seems to be no regulation of the supply of these drugs and that seems to me to inevitably put the lives of vulnerable people at risk. In this case there was no communication with Mr Dixon’s GP and I would imagine there is no way for these online companies to check whether their customers are placing duplicate orders with other websites , there seems therefore to be a situation where one could purchase almost limitless amounts of these drugs with no checks or balances at all . There seems to be no system for establishing the suitability of the purchaser, nor a system to limit the amount or frequency of medication being purchased .
” 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 Disrupt access to the illicit website through search-engine delisting, parental-control blocking, industry referrals and registry takedown requests.
Verbatim wording from the response “The MHRA can confirm that the website in question is subject to an active criminal investigation, and that arrests had been made prior to the issuing of the Regulation 28 Report. The MHRA has also issued multiple formal requests to the registrar (the company that manages the website's domain name) to suspend the website, which has thus far been unsuccessful. Other MHRA efforts to minimise the risk this website poses to the public have included:” Source location Joint response from DHSC and Department of Science Information and Technology (on behalf of DCMS)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore preventative online-safety measures with Ofcom under the Online Safety Act.
Verbatim wording from the response “Through a combination of public empowerment, technological innovation, traditional methods of law enforcement and close collaboration with partners, the MHRA is constantly working to develop new and innovative ways to tackle the online trade in illegal medicines. Some of these future criminal countermeasures will include:” Source location Joint response from DHSC and Department of Science Information and Technology (on behalf of DCMS)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Investigate the illicit website through the MHRA criminal enforcement process.
Verbatim wording from the response “The MHRA can confirm that the website in question is subject to an active criminal investigation, and that arrests had been made prior to the issuing of the Regulation 28 Report. The MHRA has also issued multiple formal requests to the registrar (the company that manages the website's domain name) to suspend the website, which has thus far been unsuccessful. Other MHRA efforts to minimise the risk this website poses to the public have included:” Source location Joint response from DHSC and Department of Science Information and Technology (on behalf of DCMS)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop targeted ISP filtering with search engines and UK internet service providers to block harmful online medicines content.
Verbatim wording from the response “Through a combination of public empowerment, technological innovation, traditional methods of law enforcement and close collaboration with partners, the MHRA is constantly working to develop new and innovative ways to tackle the online trade in illegal medicines. Some of these future criminal countermeasures will include:” Source location Joint response from DHSC and Department of Science Information and Technology (on behalf of DCMS)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand collaboration with UK Border Force to increase border operations and seizures of illegally trafficked medicines.
Verbatim wording from the response “Through a combination of public empowerment, technological innovation, traditional methods of law enforcement and close collaboration with partners, the MHRA is constantly working to develop new and innovative ways to tackle the online trade in illegal medicines. Some of these future criminal countermeasures will include:” Source location Joint response from DHSC and Department of Science Information and Technology (on behalf of DCMS)
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for the unregistered overseas supplier falls to the MHRA rather than the General Pharmaceutical Council.
Verbatim wording from the response “The GPhC regulates pharmacists, pharmacy technicians and pharmacies in Great Britain. The company ████████ is not a business registered with the GPhC and operates outside the UK jurisdiction. As such, this matter falls to the MHRA.” Source location Joint response from DHSC and Department of Science Information and Technology (on behalf of DCMS)
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 UK law enforcement cannot seize or compel suspension of illicit domains registered beyond UK jurisdiction.
Verbatim wording from the response “However, the sale and supply of unregulated medicinal products is a global problem. Online portals play a significant role in transnational medicines crime and many websites proliferate across the internet. Currently, there is no legal mechanism for UK law enforcement to seize control of illicit domains or compel registrars to suspend them when domains are registered beyond the reach of UK jurisdiction. The website referenced in the Regulation 28 notice falls into this category, being registered outside of the UK.” Source location Joint response from DHSC and Department of Science Information and Technology (on behalf of DCMS)
Open published response
3 Jun 2024 Tcherno Bari · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 12 Failure to ensure police access to the written risk assessment View source Failure to provide attending police officers with the written risk rating View source Failure to maintain an accurate and up-to-date missing person policy View source Lack of police officer awareness of the required risk rating View source Failure to communicate the RCRP challenge process to BSMHFT View source Delays in communicating police disagreement with the reported risk category View source Failure to require attending constables to give particular regard to mental health clinicians’ risk expertise View source Lack of formal notification of police disagreement about risk category View source Failure of Clinical Service Managers to coordinate attempts to locate high-risk missing patients View source Failure to inform BSMHFT when missing patient investigations are closed View source Failure to invite police representatives to daily appraisal meetings View source Failure of routine monitoring to ensure completion of the risk rating View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tcherno Bari · 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
Tcherno Bari, who had been detained under the Mental Health Act and admitted to a psychiatric unit with psychotic depression, left the hospital grounds while assessed as at high risk of suicide. He was found deceased the following day, 26 September 2023, hanging from a tree in parkland outside the police search area. The principal concerns were significant gaps in multi-agency coordination, communication of risk information, use of risk-assessment procedures, and the handling of differing assessments between mental health staff and police.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure police access to the written risk assessment
Wider context from the report “(7) The BSMHFT Missing Patient Policy and RCRP do not require BSMHFT to hand attending constables a copy of the risk assessment , or require attending constables, or later the Locate team, to request a copy of the risk assessment . In the event of a conflict about risk category, requiring attending constables to take early possession of the written risk assessment may lead to the police identifying they have overlooked key information and revisit their own risk category.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 attending police officers with the written risk rating
Wider context from the report “(1) I am not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy . I am not reassured WMP officers are aware they should be provided with ‘appendix C – risk rating’. Context: I did not accept the Nurse-in-Charge routinely used ‘appendix C – risk rating’ , and police witnesses - including a Locate Sergeant, and the Head of Locate, a Detective Chief Inspector - indicated they had never seen ‘appendix C – risk rating’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an accurate and up-to-date missing person policy
Wider context from the report “(5) The BSMHFT Missing Person Policy purports to append WMP’s missing person process but makes no mention of RCRP . I am not reassured the BSMHFT Missing Person Policy is therefore accurate and up-to-date .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of police officer awareness of the required risk rating
Wider context from the report “(1) I am not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy. I am not reassured WMP officers are aware they should be provided with ‘appendix C – risk rating’ . Context: I did not accept the Nurse-in-Charge routinely used ‘appendix C – risk rating’, and police witnesses - including a Locate Sergeant, and the Head of Locate, a Detective Chief Inspector - indicated they had never seen ‘appendix C – risk rating’ .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the RCRP challenge process to BSMHFT
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT . Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it . However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process . Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later, and WMP often close missing patient investigations without informing BSMHFT.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 communicating police disagreement with the reported risk category
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT. Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it. However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process. Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later , and WMP often close missing patient investigations without informing BSMHFT.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 require attending constables to give particular regard to mental health clinicians’ risk expertise
Wider context from the report “(8) RCRP and APP do not require attending constables to have particular regard to the expertise of mental health clinicians and hesitate or be extra vigilant before rejecting their opinion on risk category. RCRP and APP appear to regard reports from mental health clinicians no differently to those from members of the public, and family and friends of the missing person . Context: police witnesses agreed that BSMHFT clinicians were the experts on mental health diagnosis, including identifying those conditions that carry an increased risk of suicide, and assessing the risk of suicide generally. However, this case demonstrates how in the heat of the moment an (inexperienced) attending constable can overlook that expertise and quickly dismiss it .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of formal notification of police disagreement about risk category
Wider context from the report “(6) RCRP does not require WMP to formally indicate to BSMHFT (i.e. via a form) when the police have taken a different view about the risk category . BSMHFT will often be unaware of the different view taken by the police rendering the ‘challenge’ process redundant and reducing the chances of the police identifying they have overlooked key information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Clinical Service Managers to coordinate attempts to locate high-risk missing patients
Wider context from the report “(3) I am not reassured BSMHFT Clinical Service Managers (‘CSMs’) are (a) coordinating the attempts to locate high-risk missing patients , and (b) inviting a representative from WMP to attend ‘daily appraisal’ meetings to discuss the high-risk missing patient’s absence as required by their missing patient policy. I am not reassured WMP officers are aware this is the CSM’s role and of the expectation of being invited to a ‘daily appraisal’. Context: this process did not happen in Mr Bari’s case, and the WMP’s Head of Locate said she was not aware of the police ever being invited by a CSM to attend a ‘daily appraisal’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 BSMHFT when missing patient investigations are closed
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT. Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it. However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process. Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later, and WMP often close missing patient investigations without informing BSMHFT .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 invite police representatives to daily appraisal meetings
Wider context from the report “(3) I am not reassured BSMHFT Clinical Service Managers (‘CSMs’) are (a) coordinating the attempts to locate high-risk missing patients, and (b) inviting a representative from WMP to attend ‘daily appraisal’ meetings to discuss the high-risk missing patient’s absence as required by their missing patient policy. I am not reassured WMP officers are aware this is the CSM’s role and of the expectation of being invited to a ‘daily appraisal’. Context: this process did not happen in Mr Bari’s case , and the WMP’s Head of Locate said she was not aware of the police ever being invited by a CSM to attend a ‘daily appraisal’ .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 routine monitoring to ensure completion of the risk rating
Wider context from the report “(2) A ‘monitoring tool’ in the BSMHFT Missing Patient Policy requires routine monitoring to ensure nurses are completing ‘appendix A’ and ‘appendix B’, but not ‘appendix C – risk rating’ . Context: I was told this is under review, however I was concerned this is still outstanding 9 months following the death .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operational and clinical partners are best placed to respond to relevant concerns and reassess local risk, communication and escalation processes.
Verbatim wording from the response “Your report raises concerns about missing persons policy and Right Care, Right Person (RCRP), and I note that you have directed your report to the Department of Health and Social Care (DHSC) as a party to the National Partnership Agreement (NPA) on RCRP. I also note that you have raised concerns with other relevant partners, including representatives from Birmingham and Solihull Mental Health NHS Foundation Trust, West Midlands Police and NHS England. Given the operational independence of police forces and the autonomy of clinical decision making, those partners are best placed to respond to some of the concerns you raise. DHSC does have a role in setting guidance and direction to the mental health sector and I will respond on these points in particular.” Source location Response from DHSC
Open published response
Concerns raised 2 Failure of electronic patient records to automatically share renal team entries between hospitals View source Failure of allergy information to automatically cross-populate between records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Glennis CONNELLY · 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
Glennis CONNELLY died at home on 11 November 2022 from end-stage renal failure due to tubulo-interstitial nephritis caused by tazocin, despite a previously identified allergy to the drug. The principal concerns were that this allergy was not recorded in the hospital records at Queens Hospital Burton upon Trent and that electronic patient records across the same trust did not automatically share allergy information.
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 electronic patient records to automatically share renal team entries between hospitals
Wider context from the report “Although the Queens Hospital Burton Upon Trent and the the Royal Derby Hospital are governed by the same hospital trust, they have different electronic patient records . Entries made by the renal team at the Royal Derby Hospital are not automatically visible to medical staff at the Queens Hospital , "allergies" do not automatically cross populate despite entries being made on the Lorenzo system and the GP records being updated on 6th & 12th February 2020.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 allergy information to automatically cross-populate between records
Wider context from the report “Although the Queens Hospital Burton Upon Trent and the the Royal Derby Hospital are governed by the same hospital trust, they have different electronic patient records. Entries made by the renal team at the Royal Derby Hospital are not automatically visible to medical staff at the Queens Hospital, "allergies" do not automatically cross populate despite entries being made on the Lorenzo system and the GP records being updated on 6th & 12th February 2020.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The University Hospitals of Derby and Burton NHS Foundation Trust will address specific local actions in its separate response.
Verbatim wording from the response “I understand that the University Hospitals of Derby and Burton NHS Foundation Trust will be separately responding to the report and commenting on specific local action in their response.” Source location Response from DHSC
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 Care Quality Commission will assess the incident and determine whether further regulatory action is needed.
Verbatim wording from the response “Where there is any death or serious injury at a provider or service registered by the CQC, the CQC will consider this in line with their specific incident guidance to identify if a patient has suffered avoidable harm or they were placed at significant risk of avoidable harm. This includes when there are issues relating to digital systems, and a specific incident review would consider the role of the system, as well as the registered providers involved.” Source location Response from DHSC
Open published response
31 May 2024 Frazer Charlie Williams · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 17 Lack of guidance on transferring prisoners under healthcare-team care between establishments View source Lack of national guidance for management and operational staff on pre-transfer prisoner handover View source Lack of consultation with receiving-prison healthcare teams about care capability View source Lack of national guidance for healthcare handover to receiving prisons View source Failure to deliver the keyworker scheme in line with national guidance View source Lack of process for recording and involving prisoners’ next of kin View source Lack of NHS and joint HMPPS guidance on identifying, managing and treating self-neglect in prisons View source Delays in transferring prisoners requiring mental health hospital admission View source Lack of a national directory of healthcare facilities and provision at individual prisons View source Lack of guidance requiring consultation with prison doctors before transferring prisoners receiving medical care View source Lack of automatic flagging of missed ACCT reviews View source Lack of ACCT quality assurance between day 7 and post-closure review View source Failure to make an immediate ambulance call when a code blue or red is raised View source Failure to invite relevant individuals such as key workers to ACCT reviews View source Lack of national specification for prison healthcare units View source Failure of the email-a-prisoner system to facilitate contact after unrecognised prisoner transfers View source Camouflaging similarity between cell-door and bedsheet colours View source See 14 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Frazer Charlie Williams · 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
Frazer Charlie Williams was found deceased on 7 March 2022 in his cell at HMP Guys Marsh, suspended by a ligature. The report identifies concerns about delays transferring prisoners requiring mental health hospital care, inadequate arrangements for managing self-neglect and healthcare handovers, shortcomings in ACCT monitoring and reviews, and other prison care and safety processes. The inquest concluded that he died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on transferring prisoners under healthcare-team care between establishments
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold . There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for management and operational staff on pre-transfer prisoner handover
Wider context from the report “vi. There is lack of national guidance for both senior management and operational prison staff in relation to the handover of a prisoner in advance of their transfer , not specific to, but especially those with complex needs, when transferring between prisons.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 consultation with receiving-prison healthcare teams about care capability
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for healthcare handover to receiving prisons
Wider context from the report “iv. There is a lack of national guidance for healthcare teams working in prisons around the handover of healthcare of a prisoner to the receiving prison when they are transferred to another prison.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 deliver the keyworker scheme in line with national guidance
Wider context from the report “x. The keyworker scheme is not being delivered in line with national guidance at HMP Guys Marsh.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 process for recording and involving prisoners’ next of kin
Wider context from the report “xiii. There is a lack of process regarding the recording of a prisoner’s next of kin and involvement of them at HMP Guys Marsh.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 NHS and joint HMPPS guidance on identifying, managing and treating self-neglect in prisons
Wider context from the report “ii. There is a lack of NHS guidance, and joint guidance with HMPPS, on the identification, management, and treatment of someone with self neglect in the prison setting .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring prisoners requiring mental health hospital admission
Wider context from the report “i. There is inequity within the system of the treatment of a person with mental illness in the prison setting compared to an individual in the community, due to the fact that in the community a person would be placed in a hospital setting on the day they were deemed to require hospital admission, however in prison there are delays in transferring a prisoner in the same situation to hospital .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a national directory of healthcare facilities and provision at individual prisons
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales , and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance requiring consultation with prison doctors before transferring prisoners receiving medical care
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care , whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold . Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 automatic flagging of missed ACCT reviews
Wider context from the report “viii. There is lack of automatic flagging of a missed ACCT review at HMP Guys Marsh and this could also be a national problem.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 ACCT quality assurance between day 7 and post-closure review
Wider context from the report “vii. The lack of ACCT quality assurance, or audit, between day 7 of the ACCT and the post closure review .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to make an immediate ambulance call when a code blue or red is raised
Wider context from the report “xii. PSI 03/2013 is not being followed at HMP Guys Marsh as there is no immediate call to the ambulance service when a code blue or red is raised .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 invite relevant individuals such as key workers to ACCT reviews
Wider context from the report “ix. Relevant individuals, such as key workers are not being invited to attend ACCT reviews at HMP Guys Marsh in line with ACCT 6 guidance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national specification for prison healthcare units
Wider context from the report “v. There is a lack of national specification in respect of prison healthcare units .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 email-a-prisoner system to facilitate contact after unrecognised prisoner transfers
Wider context from the report “xiv. The email a prisoner system is dependant on the person wanting to contact the prisoner knowing their location , so if the prisoner is transferred to another prison and the person contacting them is not aware, contact which can be a protective factor particularly in a prisoner’s mental health care, will not be facilitated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Camouflaging similarity between cell-door and bedsheet colours
Wider context from the report “xi. The colour of the cell doors and bedsheets at HMP Guys Marsh, and possibly at other prisons nationally, being very similar can camouflage ligatures .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with NHS England and His Majesty’s Prison and Probation Service to respond to concerns about delays transferring mentally unwell prisoners to hospital.
Verbatim wording from the response “I share your concerns about the length of time it can take to transfer some mentally unwell prisoners to hospital when needed, and we are taking steps to improve that. As highlighted in NHS England’s response to you, the Department is working with NHS England, and His Majesty’s Prison and Probation Service to respond to the concerns highlighted in His Majesty’s Inspectorate of Prisons’ thematic review The Long Wait, published in February 2024, which focuses on delays in the transfer of mentally unwell prisoners. NHS England is leading on this response, which I will be reviewing and I will be keeping a close eye on how this work progresses.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the Mental Health Bill during the current Parliamentary session.
Verbatim wording from the response “In addition to this, the Mental Health Bill will be introduced in this Parliamentary session. The Bill sets out vital reforms to support people with severe mental illness in the criminal justice” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the response to the thematic review and monitor progress in addressing delays transferring mentally unwell prisoners to hospital.
Verbatim wording from the response “I share your concerns about the length of time it can take to transfer some mentally unwell prisoners to hospital when needed, and we are taking steps to improve that. As highlighted in NHS England’s response to you, the Department is working with NHS England, and His Majesty’s Prison and Probation Service to respond to the concerns highlighted in His Majesty’s Inspectorate of Prisons’ thematic review The Long Wait, published in February 2024, which focuses on delays in the transfer of mentally unwell prisoners. NHS England is leading on this response, which I will be reviewing and I will be keeping a close eye on how this work progresses.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England leads the response to delays transferring mentally unwell prisoners to hospital, with the Department reviewing progress.
Verbatim wording from the response “I share your concerns about the length of time it can take to transfer some mentally unwell prisoners to hospital when needed, and we are taking steps to improve that. As highlighted in NHS England’s response to you, the Department is working with NHS England, and His Majesty’s Prison and Probation Service to respond to the concerns highlighted in His Majesty’s Inspectorate of Prisons’ thematic review The Long Wait, published in February 2024, which focuses on delays in the transfer of mentally unwell prisoners. NHS England is leading on this response, which I will be reviewing and I will be keeping a close eye on how this work progresses.” Source location Response from DHSC
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 Other report recipients are responsible for addressing prison healthcare guidance, ACCT operations and family engagement because these concern day-to-day prison operations.
Verbatim wording from the response “With regard to the other concerns you have raised around a lack of national guidance relating to a range of healthcare issues in prison settings; operational issues regarding the ACCT process and engagement with prisoners’ family members, I would expect the other recipients of your report to address these in their responses, as they are responsible for matters relating to day to day operations within prison settings. I look forward to seeing their responses and working with them where appropriate, to avoid a repetition of the horrific events of this case.” Source location Response from DHSC
Open published response
30 May 2024 Katie MADDEN · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 7 Failure to assess additional risks to vulnerable parents in safeguarding referrals concerning their children View source Failure to provide additional support for vulnerable recipients of a ‘Claires Law’ Domestic Violence Disclosure during child-care investigations View source Failure of the funding pathway to provide access to specialist psychological treatment View source Unavailability of Schema-based Cognitive Behavioural Therapy on the NHS View source Lack of risk assessment of vulnerable parents’ mental health and physical wellbeing at Public Law Outline notification View source Lack of independent Social Services support for vulnerable parents View source Lack of independent professional holistic case review for vulnerable parents View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Katie MADDEN · 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 Madden was declared deceased on 4 June 2023 after being found hanging, following a history of mental health conditions, domestic violence, and a toxic relationship. The report identified concerns about the lack of systems to assess and support her vulnerability during child-care proceedings and safeguarding processes, the absence of independent Social Services support, and difficulties obtaining funding for recommended psychological treatment.
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 assess additional risks to vulnerable parents in safeguarding referrals concerning their children
Wider context from the report “4. Safeguarding referrals made the Multi-Agency Safeguarding Hub in respect of Kate’s children were viewed in isolation , with no system in place to assess any additional risks posed to Kate herself . There were no additional steps, or risk assessments undertaken in relation to Kate , even though she was a recipient of a ‘Claires Law’ Domestic Violence Disclosure and therefore known to be more vulnerable.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 additional support for vulnerable recipients of a ‘Claires Law’ Domestic Violence Disclosure during child-care investigations
Wider context from the report “1. No evidence was seen that recipients of a ‘Claires Law’ Domestic Violence Disclosure are treated as being of greater vulnerability, or at a higher risk, when Child Services are undertaking investigations regarding the provision of children’s care, and removal of the children from a parent is being considered . It was heard in evidence that the Social Worker appointed to this case, quite properly focused on what was in the best interest of Kate’s children. There was however no formal system in place to provide additional support for Kate herself, even though she was known to be vulnerable.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 funding pathway to provide access to specialist psychological treatment
Wider context from the report “5. In 2022 it was recognised by a Clinical Psychologist that Kate could benefit from Schema-based Cognitive Behavioural Therapy, which is not routinely available on the NHS.
The psychological review had been ordered by the Family Court, and funding for this course needed to be applied for.
Applying for funding involved requests to the Legal Aid Board, Integrated Care Board (Individual Funding Request), Wellbeing Service and Social Services, none of whom provided the funding, with each suggesting contacting one of the other agencies involved .
An experienced mental health clinician with many years’ experience described the ‘whole route as very complicated’ and ‘it was difficult to find a solution for funding ’. In addition, funding was very rarely made available , and as a service they were usually unable to meet patient expectations (who believe a treatment might be made available), where in reality it almost certainly would not be available.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of Schema-based Cognitive Behavioural Therapy on the NHS
Wider context from the report “5. In 2022 it was recognised by a Clinical Psychologist that Kate could benefit from Schema-based Cognitive Behavioural Therapy, which is not routinely available on the NHS .
The psychological review had been ordered by the Family Court, and funding for this course needed to be applied for.
Applying for funding involved requests to the Legal Aid Board, Integrated Care Board (Individual Funding Request), Wellbeing Service and Social Services, none of whom provided the funding, with each suggesting contacting one of the other agencies involved.
An experienced mental health clinician with many years’ experience described the ‘whole route as very complicated’ and ‘it was difficult to find a solution for funding’. In addition, funding was very rarely made available, and as a service they were usually unable to meet patient expectations (who believe a treatment might be made available), where in reality it almost certainly would not be available.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of risk assessment of vulnerable parents’ mental health and physical wellbeing at Public Law Outline notification
Wider context from the report “2. It was identified that when Kate was informed there may be an application to the Family Court to place her children into care (using the Public Law Outline process), the impact of such a decision on her mental health, or physical wellbeing was not taken into consideration . As a recipient of a ‘Claires Law’ Domestic Violence Disclosure, it was acknowledged that she was of greater vulnerability, but no system is currently in place which allows a risk assessment to be undertaken at the time the Public Law Outline notification is given to a parent . The day after Kate was told of the Public Law Outline notification, she had intentionally crashed her car in an unsuccessful attempt to end her life, requiring 4 weeks in an Intensive Treatment Unit to recover from the serious injuries she received.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 independent Social Services support for vulnerable parents
Wider context from the report “3. Once the Public Law Outline process was initiated, independent legal advice was provided, and a voluntary sector advocate supported Kate through the legal process. However, Katie received no independent support from Social Services , and had no independent professional to undertake a holistic review of her case, in light of her known circumstances and vulnerabilities. It was heard that mental health professionals had assumed that she had a Social Worker of her own, and expressed surprise when finding out that she did not.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of independent professional holistic case review for vulnerable parents
Wider context from the report “3. Once the Public Law Outline process was initiated, independent legal advice was provided, and a voluntary sector advocate supported Kate through the legal process. However, Katie received no independent support from Social Services, and had no independent professional to undertake a holistic review of her case, in light of her known circumstances and vulnerabilities . It was heard that mental health professionals had assumed that she had a Social Worker of her own, and expressed surprise when finding out that she did not.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The relevant integrated care board, through an independent panel, determines individual funding requests for treatments not routinely available on the NHS.
Verbatim wording from the response “Regarding your concern that, following a psychological review ordered by the Family Court, the Schema-based Cognitive Behavioural Therapy treatment recommended for Katie was not made available. I regret that Katie did not get this therapy as it is not routinely available on the NHS. In such instances, the normal process would be for an individual funding request application to be made by the appropriate clinician to the relevant integrated care board (in this instance, Norfolk and Waveney ICB). This would then be considered by an independent panel made up of doctors, nurses, public health experts, pharmacists, NHS England representatives and lay members.” Source location Response from DHSC
Open published response
29 May 2024 Hayley Jayne Cowan · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 4 Lack of guidance on staff bathroom arrangements while accompanying patients on leave View source Capacity-shaped local policies for Section 17 leave View source Lack of consistency in definitions of accompanied and escorted leave View source Inconsistent guidance on whether patients should remain within eyeline or at a reasonable distance during leave 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
Hayley Jayne Cowan · 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
Hayley Jayne Cowan was detained under Section 3 of the Mental Health Act and absconded during accompanied leave to a local shop on 3 June 2022. She was found deceased the following day after using drugs; concerns included inconsistent definitions and guidance for accompanied and escorted leave, including what staff should do if they needed to use the bathroom while accompanying a patient.
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 guidance on staff bathroom arrangements while accompanying patients on leave
Wider context from the report “The court heard evidence as to the lack of consistency and clarity for Mental Health trusts in understanding and defining how Section 17 leave should be conducted. This issue was highlighted in the paper published in December 2022 ████████, “NHS mental health services policies on leave for detained patients in England and Wales: A national audit.” Journal Psychiatric Mental Health Nursing 2023; 30: 719-730.
- Local policies appear to be shaped as a result of capacity
- There is a lack of consistency as to how “accompanied leave” and “escorted leave” are defined.
- Guidance as to whether a patient should remain in “eye-line” or at a “reasonable distance” is inconsistent and does not assist trusts in considering how trusts should work.
The Mental Health Act Codes of Practice, Guidance from the MOJ to Forensic providers and Trust policy are inconsistent. This is particularly the case in considering whether a patient needs to be within “eyeline” or a “reasonable distance” when on leave. There is also no guidance as to how trusts instruct staff on practical matters such as what to do if the staff member needs the bathroom whilst out with a patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Capacity-shaped local policies for Section 17 leave
Wider context from the report “The court heard evidence as to the lack of consistency and clarity for Mental Health trusts in understanding and defining how Section 17 leave should be conducted . This issue was highlighted in the paper published in December 2022 ████████, “NHS mental health services policies on leave for detained patients in England and Wales: A national audit.” Journal Psychiatric Mental Health Nursing 2023; 30: 719-730.
- Local policies appear to be shaped as a result of capacity
- There is a lack of consistency as to how “accompanied leave” and “escorted leave” are defined.
- Guidance as to whether a patient should remain in “eye-line” or at a “reasonable distance” is inconsistent and does not assist trusts in considering how trusts should work.
The Mental Health Act Codes of Practice, Guidance from the MOJ to Forensic providers and Trust policy are inconsistent. This is particularly the case in considering whether a patient needs to be within “eyeline” or a “reasonable distance” when on leave. There is also no guidance as to how trusts instruct staff on practical matters such as what to do if the staff member needs the bathroom whilst out with a patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of consistency in definitions of accompanied and escorted leave
Wider context from the report “The court heard evidence as to the lack of consistency and clarity for Mental Health trusts in understanding and defining how Section 17 leave should be conducted. This issue was highlighted in the paper published in December 2022 ████████, “NHS mental health services policies on leave for detained patients in England and Wales: A national audit.” Journal Psychiatric Mental Health Nursing 2023; 30: 719-730.
- Local policies appear to be shaped as a result of capacity
- There is a lack of consistency as to how “accompanied leave” and “escorted leave” are defined.
- Guidance as to whether a patient should remain in “eye-line” or at a “reasonable distance” is inconsistent and does not assist trusts in considering how trusts should work.
The Mental Health Act Codes of Practice, Guidance from the MOJ to Forensic providers and Trust policy are inconsistent. This is particularly the case in considering whether a patient needs to be within “eyeline” or a “reasonable distance” when on leave. There is also no guidance as to how trusts instruct staff on practical matters such as what to do if the staff member needs the bathroom whilst out with a patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistent guidance on whether patients should remain within eyeline or at a reasonable distance during leave
Wider context from the report “The court heard evidence as to the lack of consistency and clarity for Mental Health trusts in understanding and defining how Section 17 leave should be conducted. This issue was highlighted in the paper published in December 2022 ████████, “NHS mental health services policies on leave for detained patients in England and Wales: A national audit.” Journal Psychiatric Mental Health Nursing 2023; 30: 719-730.
- Local policies appear to be shaped as a result of capacity
- There is a lack of consistency as to how “accompanied leave” and “escorted leave” are defined.
- Guidance as to whether a patient should remain in “eye-line” or at a “reasonable distance” is inconsistent and does not assist trusts in considering how trusts should work.
The Mental Health Act Codes of Practice, Guidance from the MOJ to Forensic providers and Trust policy are inconsistent. This is particularly the case in considering whether a patient needs to be within “eyeline” or a “reasonable distance” when on leave. There is also no guidance as to how trusts instruct staff on practical matters such as what to do if the staff member needs the bathroom whilst out with a patient.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the Mental Health Act Code of Practice after introducing the reform legislation.
Verbatim wording from the response “Regarding your comments on the inconsistencies between the Mental Health Act Code of Practice, guidance from the Ministry of Justice, and local Trust policy, this Government has announced we will be bringing forward legislation to reform the Mental Health Act in this Parliamentary Session. We will subsequently be revising the Code of Practice, and will be considering where further changes can be made to strengthen statutory guidance. We will consider the issues you have raised as part of that work.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider the reported inconsistencies and identify further changes to strengthen statutory guidance.
Verbatim wording from the response “Regarding your comments on the inconsistencies between the Mental Health Act Code of Practice, guidance from the Ministry of Justice, and local Trust policy, this Government has announced we will be bringing forward legislation to reform the Mental Health Act in this Parliamentary Session. We will subsequently be revising the Code of Practice, and will be considering where further changes can be made to strengthen statutory guidance. We will consider the issues you have raised as part of that work.” Source location Response from DHSC
Open published response
29 May 2024 John Richard Hartey · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Insufficient District Nursing and Community Specialist Practitioner capacity to see patients in accordance with their needs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Richard Hartey · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Richard Hartey was found dead at home on 20 October 2023. His death was attributed to congestive cardiac failure against a background of hypertensive heart disease and Type 1 Diabetes Mellitus, with acute bronchitis and transplant immunosuppression contributing. The court heard concern that a national shortage of District Nurses and Community Specialist Practitioners could delay patients being seen in accordance with their needs.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient District Nursing and Community Specialist Practitioner capacity to see patients in accordance with their needs
Wider context from the report “It is a matter of concern that a national shortage of District Nurses / Community Specialist Practitioners can lead to a delay in patients being seen in accordance with their needs .
” 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 Train the staff the NHS needs to provide care when patients need it.
Verbatim wording from the response “We have set out a clear commitment to move to a neighbourhood health service, with more care delivered in local communities to spot problems earlier, this includes over time shifting resources to primary care and community services. In the longer term, we are committed to training the staff the NHS needs to be there for patients when they need it.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Move toward a neighbourhood health service by delivering more care in local communities and shifting resources over time to primary and community services.
Verbatim wording from the response “We have set out a clear commitment to move to a neighbourhood health service, with more care delivered in local communities to spot problems earlier, this includes over time shifting resources to primary care and community services. In the longer term, we are committed to training the staff the NHS needs to be there for patients when they need it.” Source location Response from DHSC
Open published response
29 May 2024 Elizabeth Sarah Jayne McCann · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 19 Inadequate management structure and oversight in the health and wellbeing college View source Failure to comply with GDPR in the health and wellbeing college View source Inadequate safeguarding provisions in health and wellbeing colleges View source Insufficient probation staffing capacity View source High proportion of probation officers with limited service and experience View source Limited information-sharing protocols between probation and partner services View source Lack of professional curiosity by senior GMP officers View source Poor-quality GMP investigations and reports View source Insufficient staffing of sexual offender management units View source Poor-quality investigations failing to generate organisational learning View source Failure to provide adequate supervision and support to newly qualified probation staff View source Insufficient professional curiosity among staff dealing with high-risk offenders View source Ineffective information-sharing protocols in health and wellbeing colleges View source Sexual offender management caseloads exceeding safe levels View source Insufficiently clear and understood risk-management protocols in health and wellbeing colleges View source Failure to escalate investigation reports for senior consideration View source Referrals to health and wellbeing services without risk-management protocols View source Inadequate systems for managing risk in the health and wellbeing college View source Lack of an information-sharing protocol between the health and wellbeing college and probation View source See 16 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elizabeth Sarah Jayne McCann · 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
Elizabeth Sarah Jayne McCann was raped and murdered on 25 August 2022 at the home address of her murderer. The report identifies failures in risk assessment, information sharing, safeguarding, and management of a high-risk offender by the Health and Wellbeing College, Probation, and Greater Manchester Police. It also identifies concerns about excessive caseloads, inadequate staffing, supervision, recording, and organisational learning.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate management structure and oversight in the health and wellbeing college
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight , lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 comply with GDPR in the health and wellbeing college
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 safeguarding provisions in health and wellbeing colleges
Wider context from the report “10. The inquest was told that Health and Well Being Colleges could provide effective support for the communities they served. They were a national model. However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed with clear, documented protocols understood by all in place. There was also a need for effective information sharing protocols and effective well understood safeguarding provisions .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 probation staffing capacity
Wider context from the report “1. The inquest heard evidence that the probation staff were carrying significant caseloads . This was due to challenges in recruiting sufficient staff . The evidence was that there is still a national shortage of probation officers . Steps have been taken to recruit and train further probation officers which provides some assistance but means that overall, a significant number of probation officers are young in service and experience.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation High proportion of probation officers with limited service and experience
Wider context from the report “1. The inquest heard evidence that the probation staff were carrying significant caseloads. This was due to challenges in recruiting sufficient staff. The evidence was that there is still a national shortage of probation officers. Steps have been taken to recruit and train further probation officers which provides some assistance but means that overall, a significant number of probation officers are young in service and experience .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Limited information-sharing protocols between probation and partner services
Wider context from the report “4. Clear Information Sharing protocols between Probation and such groups as drug and alcohol services were limited . Without clear agreements understood by both sides there was a significant risk that crucial information that impacted risk assessments would not be shared .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 professional curiosity by senior GMP officers
Wider context from the report “8. There was no evidence before the inquest of any professional curiosity by senior GMP officers as to the role of GMP and if lessons could be learnt . It was unclear as to why senior officers were unsighted .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor-quality GMP investigations and reports
Wider context from the report “7. The GMP investigation into their role in relation to Elizabeth’s death was poor in quality and there was no evidence that any senior officer had considered the report. The inquest was told that the quality and lack of referral upwards of a report was not unique to Elizabeth’s case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing of sexual offender management units
Wider context from the report “5. The inquest was told that nationally a significant number of police forces were struggling to adequately staff their Sexual Offender Management Units . As a consequence, the level of supervision of sex offenders in the community was being risk managed posing a risk to communities.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor-quality investigations failing to generate organisational learning
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed . This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 adequate supervision and support to newly qualified probation staff
Wider context from the report “2. The evidence before the inquest was that it was important that newly qualified probation staff were closely supervised and supported by their managers . Without that supervision performance issues identified by the trackers were not being tackled . Ensuring this had been and was challenging as the number of staff line managed by senior probation officers had been too high . This was being addressed but was only achievable if sufficient senior staff were retained.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient professional curiosity among staff dealing with high-risk offenders
Wider context from the report “9. It was accepted that there needed to be a level of professional curiosity by staff dealing with high-risk offenders such as in this case and that training for probation officers and police staff needed to reinforce that.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Ineffective information-sharing protocols in health and wellbeing colleges
Wider context from the report “10. The inquest was told that Health and Well Being Colleges could provide effective support for the communities they served. They were a national model. However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed with clear, documented protocols understood by all in place. There was also a need for effective information sharing protocols and effective well understood safeguarding provisions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Sexual offender management caseloads exceeding safe levels
Wider context from the report “6. In the case of Greater Manchester Police, the staffing issues had been known by senior managers for a number of years (many years before Covid) and a decision taken to risk mange far below the appropriate staffing numbers taken. The consequence was that the staff in the unit could not effectively manage their caseloads that were far in excess of the recommended level . The numbers in the unit were increasing but the caseloads were still high.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 clear and understood risk-management protocols in health and wellbeing colleges
Wider context from the report “10. The inquest was told that Health and Well Being Colleges could provide effective support for the communities they served. They were a national model. However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed with clear, documented protocols understood by all in place . There was also a need for effective information sharing protocols and effective well understood safeguarding provisions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate investigation reports for senior consideration
Wider context from the report “7. The GMP investigation into their role in relation to Elizabeth’s death was poor in quality and there was no evidence that any senior officer had considered the report . The inquest was told that the quality and lack of referral upwards of a report was not unique to Elizabeth’s case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Referrals to health and wellbeing services without risk-management protocols
Wider context from the report “3. Evidence before the inquest was that if probation referred clients under supervision to places such as the Health and Wellbeing College this would, if not implemented effectively pose a significant risk to vulnerable users of such institutions. If referrals were made without a protocol being in place that dealt with managing risk then the risk posed increased further.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 systems for managing risk in the health and wellbeing college
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of an information-sharing protocol between the health and wellbeing college and probation
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight, lack of an information sharing protocol with probation , the systems in the college for managing risk and sharing information and compliance with GDPR.
” 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 and support compliance with a more robust safeguarding policy for College enrollees.
Verbatim wording from the response “The Trust's safeguarding leads have supported College leads in developing more robust safeguarding policy for enrollees at the College. The safeguarding team has provided additional learning sessions to college staff and volunteers and there is a rolling programme of support in place. College leads report compliance with safeguarding training through newly established governance systems and are also receiving support to access and utilise core governance processes such as reporting and management of risk in accordance with the expectations within the organisation.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct the externally commissioned review of the Health and Wellbeing College’s risk management protocols.
Verbatim wording from the response “I have been informed that prior to your report being issued, the Trust had already commissioned an external review of the Health and Wellbeing College, which is currently ongoing. The Network Director of Quality, Nursing and Health Professionals for the South Network is working with the team there in relation to risk management systems and processes.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide safeguarding learning sessions and an ongoing support programme for College staff and volunteers.
Verbatim wording from the response “The Trust's safeguarding leads have supported College leads in developing more robust safeguarding policy for enrollees at the College. The safeguarding team has provided additional learning sessions to college staff and volunteers and there is a rolling programme of support in place. College leads report compliance with safeguarding training through newly established governance systems and are also receiving support to access and utilise core governance processes such as reporting and management of risk in accordance with the expectations within the organisation.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop risk management systems and processes for the Health and Wellbeing College.
Verbatim wording from the response “I have been informed that prior to your report being issued, the Trust had already commissioned an external review of the Health and Wellbeing College, which is currently ongoing. The Network Director of Quality, Nursing and Health Professionals for the South Network is working with the team there in relation to risk management systems and processes.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an enrolment standard operating procedure requiring agency, clinical-record and risk checks, consent-based liaison, and clinical-team input on enrolment.
Verbatim wording from the response “Since the incident occurred, the College has developed a standard operating procedure outlining steps and processes required by College leads and administrators in relation to information required by the College for every student's successful enrolment to commence. These checks include self-disclosure by prospective students relating to activity and engagement with other agencies in addition to checks against internal clinical and security systems.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish governance systems for safeguarding-training compliance, risk reporting and access to core governance processes.
Verbatim wording from the response “The Trust's safeguarding leads have supported College leads in developing more robust safeguarding policy for enrollees at the College. The safeguarding team has provided additional learning sessions to college staff and volunteers and there is a rolling programme of support in place. College leads report compliance with safeguarding training through newly established governance systems and are also receiving support to access and utilise core governance processes such as reporting and management of risk in accordance with the expectations within the organisation.” Source location Response from DHSC
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 Most concerns fall to the Ministry of Justice, Home Office and Greater Manchester Police, which will respond to the report.
Verbatim wording from the response “Most of the concerns you have raised are matters for the Ministry of Justice, Home Office and Greater Manchester Police and I understand that these organisations will be responding to your report.” Source location Response from DHSC
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 Concerns about health and wellbeing colleges are assigned to NHS England and Pennine Care NHS Foundation Trust, with the Trust responding directly.
Verbatim wording from the response “You have also raised concerns about health and wellbeing colleges and, in preparing this response, Departmental officials have made enquiries with NHS England and Pennine Care NHS Foundation Trust. I understand that the Trust is also in the process of responding to you directly.” Source location Response from DHSC
Open published response
23 May 2024 Jada Monoja · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Failure to clearly date and signpost revisions within compound risk assessments View source Failure to systematically review and update risk indicators at relevant patient events View source Failure to maintain detailed patient risk assessments as clear, well-signposted and dated assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jada Monoja · 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
Jada Monoja, who had a history of chronic paranoid and delusional thinking, disclosed suicidal thoughts on 15 November 2020 and was assessed by mental health services before being accepted by the Home Treatment Team. In the early hours of 17 November 2020, he was found unresponsive after leaving home and could not be resuscitated; the inquest concluded that he died by suicide, likely while experiencing delusional and paranoid thoughts. The principal concerns relate to the use of the online risk assessment tool, including assessments being incomplete, insufficiently dated or signposted, and difficult to identify within chronological records.
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 clearly date and signpost revisions within compound risk assessments
Wider context from the report “Multiple witnesses indicated that the Risk Assessment Tool on the online system (EPJS) is not used in line with policy (i.e. that a new assessment in that tool is undertaken at the time of each admission/discharge/major risk event etc.), and, if updated, may only be updated in so far as additional narrative is added to the last such narrative in a previously completed assessment.
Further, the evidence was that rather than be used for a detailed assessment per the indicators set out in the tool at the time of each relevant event, it was reviewed to instead access any past assessment in order (only) to establish quickly a benchmark against which the gauge a patient’s current presentation when considering their risks. The detailed indicators informing the risk assessment were not updated.
Although it was submitted that patient risk was nonetheless assessed and recorded in the EPJS, and acknowledged that benchmarking/comparison is useful, I am concerned that:
(1) if the risk indicators set out in the tool are not systematically reviewed or reconsidered, then the assessment of risk that follows will then be based on incomplete, and therefore misleading, information; and
(2) absent the above, and dating of revisions within a compound document, it is not clear on what indicators any assessment is in fact based
(3) to the extent the risk assessment is used as a benchmarking tool, the impression given to the most recent reviewer is then likely to be incomplete and misleading;
(4) the apparent current use of the tool to establish a point of benchmarking/comparison is in any event lost where the compound narrative assessments are not clearly dated and signposted ;
(5) if the detailed patient assessment is instead placed as a new entry in the general chronological notes, the usefulness of the tool as a clear, well signposted, dated assessment and documentation of the patients of risk(s), is lost, requiring a reviewer to instead review the general chronological log of entries on the EPJS where it is not required to be articulated in the same terms, and may be more difficult to identify in a longstanding patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to systematically review and update risk indicators at relevant patient events
Wider context from the report “Multiple witnesses indicated that the Risk Assessment Tool on the online system (EPJS) is not used in line with policy (i.e. that a new assessment in that tool is undertaken at the time of each admission/discharge/major risk event etc. ), and, if updated, may only be updated in so far as additional narrative is added to the last such narrative in a previously completed assessment.
Further, the evidence was that rather than be used for a detailed assessment per the indicators set out in the tool at the time of each relevant event , it was reviewed to instead access any past assessment in order (only) to establish quickly a benchmark against which the gauge a patient’s current presentation when considering their risks. The detailed indicators informing the risk assessment were not updated.
Although it was submitted that patient risk was nonetheless assessed and recorded in the EPJS, and acknowledged that benchmarking/comparison is useful, I am concerned that:
(1) if the risk indicators set out in the tool are not systematically reviewed or reconsidered , then the assessment of risk that follows will then be based on incomplete, and therefore misleading, information ; and
(2) absent the above, and dating of revisions within a compound document, it is not clear on what indicators any assessment is in fact based
(3) to the extent the risk assessment is used as a benchmarking tool, the impression given to the most recent reviewer is then likely to be incomplete and misleading;
(4) the apparent current use of the tool to establish a point of benchmarking/comparison is in any event lost where the compound narrative assessments are not clearly dated and signposted ;
(5) if the detailed patient assessment is instead placed as a new entry in the general chronological notes, the usefulness of the tool as a clear, well signposted, dated assessment and documentation of the patients of risk(s), is lost, requiring a reviewer to instead review the general chronological log of entries on the EPJS where it is not required to be articulated in the same terms, and may be more difficult to identify in a longstanding patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain detailed patient risk assessments as clear, well-signposted and dated assessments
Wider context from the report “Multiple witnesses indicated that the Risk Assessment Tool on the online system (EPJS) is not used in line with policy (i.e. that a new assessment in that tool is undertaken at the time of each admission/discharge/major risk event etc.), and, if updated, may only be updated in so far as additional narrative is added to the last such narrative in a previously completed assessment.
Further, the evidence was that rather than be used for a detailed assessment per the indicators set out in the tool at the time of each relevant event, it was reviewed to instead access any past assessment in order (only) to establish quickly a benchmark against which the gauge a patient’s current presentation when considering their risks. The detailed indicators informing the risk assessment were not updated.
Although it was submitted that patient risk was nonetheless assessed and recorded in the EPJS, and acknowledged that benchmarking/comparison is useful, I am concerned that:
(1) if the risk indicators set out in the tool are not systematically reviewed or reconsidered, then the assessment of risk that follows will then be based on incomplete, and therefore misleading, information; and
(2) absent the above, and dating of revisions within a compound document, it is not clear on what indicators any assessment is in fact based
(3) to the extent the risk assessment is used as a benchmarking tool, the impression given to the most recent reviewer is then likely to be incomplete and misleading;
(4) the apparent current use of the tool to establish a point of benchmarking/comparison is in any event lost where the compound narrative assessments are not clearly dated and signposted ;
(5) if the detailed patient assessment is instead placed as a new entry in the general chronological notes , the usefulness of the tool as a clear, well signposted, dated assessment and documentation of the patients of risk(s), is lost , requiring a reviewer to instead review the general chronological log of entries on the EPJS where it is not required to be articulated in the same terms, and may be more difficult to identify in a longstanding patient .
” 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 Specific concerns about the Trust’s electronic risk assessment tool should be addressed by Oxleas NHS Foundation Trust and NHS England.
Verbatim wording from the response “The specific details of your concerns should be addressed in the responses from the Oxleas NHS Foundation Trust and NHS England. However, we recognise the issues associated with the use of risk assessment tools in the care of people who may be at risk of suicide. The ability of clinicians to identify and manage an individual’s risk of suicide is critical to enabling treatment and longer-term support that can help to reduce suicidal risk. However, risk assessment tools and scales, used in isolation, cannot accurately predict risk of self-harm or suicide and any use of such tools must only be as part of a wider, person-centred conversation to best understand and assess an individual’s suicidal risk.” Source location Response from DHSC
Open published response
15 May 2024 Gary David Ash · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Lack of knowledge of neuroleptic malignant syndrome management and appropriate Dantrolene use View source Lack of knowledge of the Dantrolene–Labetalol interaction reducing cardiac contractility View source Lack of knowledge of serotonin syndrome diagnosis and risk following combined Fentanyl and Ondansetron use View source Lack of knowledge of Dantrolene-associated pulmonary oedema risk during intravenous fluid overload 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
Gary David Ash · 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 David Ash died at Queen's Hospital on 25 June 2019 after developing serotonin syndrome shortly after receiving a general anaesthetic without valid consent. He subsequently received large amounts of intravenous fluid, developed fluid overload and pulmonary oedema, and suffered a cardiac arrest. The principal concerns included knowledge and management of neuroleptic malignant syndrome and serotonin syndrome, use of Dantrolene, fluid monitoring, and potential drug interactions affecting cardiac contractility.
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 knowledge of neuroleptic malignant syndrome management and appropriate Dantrolene use
Wider context from the report “The Inquest heard evidence from an expert (Professor of Anaesthesia), who has a specialist expertise in adverse drug reactions following anaesthesia and specialist expertise in the conditions of neuroleptic malignant syndrome and malignant hyperthermia. The Professor raised concern, which was reflected in the inquest evidence, in relation to general medical knowledge relating to the following:
1. Management of the condition neuroleptic malignant syndrome, including the inappropriate, off licence, use of Dantrolene.
2. The role of Dantrolene in the development of pulmonary oedema in the presence of intravenous fluid overload.
3. The potential interaction between Dantrolene and Labetalol in relation to the reduction of cardiac contractility.
4. The lack of knowledge around the diagnosis of serotonin syndrome and the risk of it developing following the combined use of Fentanyl and Ondansetron as part of anaesthesia.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 of the Dantrolene–Labetalol interaction reducing cardiac contractility
Wider context from the report “The Inquest heard evidence from an expert (Professor of Anaesthesia), who has a specialist expertise in adverse drug reactions following anaesthesia and specialist expertise in the conditions of neuroleptic malignant syndrome and malignant hyperthermia. The Professor raised concern, which was reflected in the inquest evidence, in relation to general medical knowledge relating to the following:
1. Management of the condition neuroleptic malignant syndrome, including the inappropriate, off licence, use of Dantrolene.
2. The role of Dantrolene in the development of pulmonary oedema in the presence of intravenous fluid overload.
3. The potential interaction between Dantrolene and Labetalol in relation to the reduction of cardiac contractility.
4. The lack of knowledge around the diagnosis of serotonin syndrome and the risk of it developing following the combined use of Fentanyl and Ondansetron as part of anaesthesia.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 of serotonin syndrome diagnosis and risk following combined Fentanyl and Ondansetron use
Wider context from the report “The Inquest heard evidence from an expert (Professor of Anaesthesia), who has a specialist expertise in adverse drug reactions following anaesthesia and specialist expertise in the conditions of neuroleptic malignant syndrome and malignant hyperthermia. The Professor raised concern, which was reflected in the inquest evidence, in relation to general medical knowledge relating to the following:
1. Management of the condition neuroleptic malignant syndrome, including the inappropriate, off licence, use of Dantrolene.
2. The role of Dantrolene in the development of pulmonary oedema in the presence of intravenous fluid overload.
3. The potential interaction between Dantrolene and Labetalol in relation to the reduction of cardiac contractility.
4. The lack of knowledge around the diagnosis of serotonin syndrome and the risk of it developing following the combined use of Fentanyl and Ondansetron as part of anaesthesia.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 of Dantrolene-associated pulmonary oedema risk during intravenous fluid overload
Wider context from the report “The Inquest heard evidence from an expert (Professor of Anaesthesia), who has a specialist expertise in adverse drug reactions following anaesthesia and specialist expertise in the conditions of neuroleptic malignant syndrome and malignant hyperthermia. The Professor raised concern, which was reflected in the inquest evidence, in relation to general medical knowledge relating to the following:
1. Management of the condition neuroleptic malignant syndrome, including the inappropriate, off licence, use of Dantrolene.
2. The role of Dantrolene in the development of pulmonary oedema in the presence of intravenous fluid overload.
3. The potential interaction between Dantrolene and Labetalol in relation to the reduction of cardiac contractility.
4. The lack of knowledge around the diagnosis of serotonin syndrome and the risk of it developing following the combined use of Fentanyl and Ondansetron as part of anaesthesia.
” Open source report
15 May 2024 Mr Benjamin Sulzbacher · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Unclear eligibility for NHS discharge service referral for private paying inpatients View source Lack of understanding of NHS community discharge 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
Mr Benjamin Sulzbacher · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Benjamin Sulzbacher had experienced deteriorating mental health and was admitted to a private hospital after attempting to tie a ligature at home. After discharge, no referral was made to the NHS Home Based Treatment Team, and he died after tying a ligature on 27 September 2023. Concerns included uncertainty among services about NHS discharge support for private inpatients and a lack of understanding at the Priory about the community services available.
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 Unclear eligibility for NHS discharge service referral for private paying inpatients
Wider context from the report “1. It was unclear to all services as to whether a private paying inpatient (who would have qualified for care under the NHS but due to bed availability went private) would be entitled to be referred to the discharge services offered by the NHS . The NHS provides more than the private sector in respect of community discharge packages and can be engaged with someone for longer. Importantly the face to face contact enables a better understanding of how a patient is actually presenting when considering their mental health.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of NHS community discharge services
Wider context from the report “1. There was a lack of understanding from the Priory witnesses as to what the NHS community services could offer on discharge . The court heard that the Home Based Treatment Team was understood to simply be a “Crisis team” which was incorrect .
” Open source report
Concerns raised 11 Absence of a planned route back to mental health assessment View source Failure to distinguish GP requests for advice from referrals View source Lack of professional curiosity about drug-taking and its clinical contribution View source Lack of continuity in primary care after patient relocation View source Delays in responding to GP requests for mental health advice due to staffing shortages View source Discharging referrals without clinical triage of non-response View source Failure to adapt patient contact methods to known communication needs View source Failure to share relevant presentation information with family View source Delays in recording family-provided clinical timelines View source Failure to advise Nearest Relatives of statutory rights to request MHA assessment View source Inaccurate or incomplete discharge summaries failing to record diagnostic uncertainty View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sally Poynton · 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
Sally Poynton, aged 44, was fatally stabbed by her son on 22 June 2021. The report raised concerns about failures in mental-health assessment and follow-up, including inadequate discharge information, difficulties obtaining reassessment, referral handling, communication with family, and discharge without clinical consideration despite signs of deteriorating mental health.
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 Absence of a planned route back to mental health assessment
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to distinguish GP requests for advice from referrals
Wider context from the report “2) Community Mental Health Team
i) There was a delay of one month in responding to a letter requesting advice from a GP. This was said to be due to staff shortages. At inquest it was noted that, 3.5 years later, staff shortages remain.
I am aware the ICB has made concerted efforts to recruit. This is a concern that appears to require attention from central government and so this point needs addressing by the Secretary of State. I note this is not the first occasion I have written to the Minister to make her aware of the persisting difficulties in recruiting mental health staff in Cornwall and the Isles of Scilly.
ii) A letter requesting advice was treated as a referral (twice.) It was accepted in evidence that there appeared to be confusion on the part of CMHT staff about how to treat a letter from a GP notwithstanding it set out clearly it was a request for advice.
iii) Once the letter from the GP was taken as a request for a referral, attempting to contact the patient by telephone. It was known Jacob was selectively mute and so it should have been readily apparent he was not going to respond. Policy appears to have been followed without consideration of the clinical circumstances.
iv) Discharging a patient’s referral without any clinical judgment. ████████ referral was discharged after he did not answer his phone twice (as he wouldn’t, being mute) or respond to an opt-in letter (that was sent to the wrong address.) The evidence was clear that ████████ lacked insight into his condition and steadfastly refused all offers of support. He was not going to ‘opt-in’ voluntarily. What appeared from the evidence to be a blanket policy of discharging patients who fail to respond (because they are unwell and lack insight) will result in those patients most in need of care being wrongly discharged. In my view, there needs to be some form of triage or clinical attention given to why a patient has not responded and whether it is appropriate to discharge.
I recognise that this consideration, in addition to informing Nearest Relatives of their right to request a MHA, will result in additional burdens for what is an already over-stretched workforce. This may be a matter for the Minister to reflect upon in considering the staffing issue highlighted above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 professional curiosity about drug-taking and its clinical contribution
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of continuity in primary care after patient relocation
Wider context from the report “Primary Care
There was an accepted lack in continuity in ████████ primary care after he moved from Sally’s address (and a GP in Marazion) to his father’s house in Ponsanooth (and a GP in Penryn.)
The inquest was told that there are now regular Multi Agency Safeguarding Hubs (MASH) where patients who may be known to both the mental health service and adult safeguarding are discussed.
It struck me that there may be value in someone from the ICB attending MASH meetings on behalf of GPs in Cornwall. That individual could then feed back information to the surgery where a patient was registered. In this instance, that would have provided ████████ with the ‘backstory’ she did not have, now being in receipt of ████████ records or the discharge summary from Longreach when she saw him and given the difficulties associated with taking a history from Jacob when he was mute.
I wonder if you feel an initiative in this regard would be sensible?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 responding to GP requests for mental health advice due to staffing shortages
Wider context from the report “2) Community Mental Health Team
i) There was a delay of one month in responding to a letter requesting advice from a GP . This was said to be due to staff shortages. At inquest it was noted that, 3.5 years later, staff shortages remain .
I am aware the ICB has made concerted efforts to recruit. This is a concern that appears to require attention from central government and so this point needs addressing by the Secretary of State. I note this is not the first occasion I have written to the Minister to make her aware of the persisting difficulties in recruiting mental health staff in Cornwall and the Isles of Scilly.
ii) A letter requesting advice was treated as a referral (twice.) It was accepted in evidence that there appeared to be confusion on the part of CMHT staff about how to treat a letter from a GP notwithstanding it set out clearly it was a request for advice.
iii) Once the letter from the GP was taken as a request for a referral, attempting to contact the patient by telephone. It was known Jacob was selectively mute and so it should have been readily apparent he was not going to respond. Policy appears to have been followed without consideration of the clinical circumstances.
iv) Discharging a patient’s referral without any clinical judgment. ████████ referral was discharged after he did not answer his phone twice (as he wouldn’t, being mute) or respond to an opt-in letter (that was sent to the wrong address.) The evidence was clear that ████████ lacked insight into his condition and steadfastly refused all offers of support. He was not going to ‘opt-in’ voluntarily. What appeared from the evidence to be a blanket policy of discharging patients who fail to respond (because they are unwell and lack insight) will result in those patients most in need of care being wrongly discharged. In my view, there needs to be some form of triage or clinical attention given to why a patient has not responded and whether it is appropriate to discharge.
I recognise that this consideration, in addition to informing Nearest Relatives of their right to request a MHA, will result in additional burdens for what is an already over-stretched workforce. This may be a matter for the Minister to reflect upon in considering the staffing issue highlighted above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Discharging referrals without clinical triage of non-response
Wider context from the report “2) Community Mental Health Team
i) There was a delay of one month in responding to a letter requesting advice from a GP. This was said to be due to staff shortages. At inquest it was noted that, 3.5 years later, staff shortages remain.
I am aware the ICB has made concerted efforts to recruit. This is a concern that appears to require attention from central government and so this point needs addressing by the Secretary of State. I note this is not the first occasion I have written to the Minister to make her aware of the persisting difficulties in recruiting mental health staff in Cornwall and the Isles of Scilly.
ii) A letter requesting advice was treated as a referral (twice.) It was accepted in evidence that there appeared to be confusion on the part of CMHT staff about how to treat a letter from a GP notwithstanding it set out clearly it was a request for advice.
iii) Once the letter from the GP was taken as a request for a referral, attempting to contact the patient by telephone. It was known Jacob was selectively mute and so it should have been readily apparent he was not going to respond. Policy appears to have been followed without consideration of the clinical circumstances.
iv) Discharging a patient’s referral without any clinical judgment . ████████ referral was discharged after he did not answer his phone twice (as he wouldn’t, being mute) or respond to an opt-in letter (that was sent to the wrong address.) The evidence was clear that ████████ lacked insight into his condition and steadfastly refused all offers of support. He was not going to ‘opt-in’ voluntarily. What appeared from the evidence to be a blanket policy of discharging patients who fail to respond (because they are unwell and lack insight) will result in those patients most in need of care being wrongly discharged. In my view, there needs to be some form of triage or clinical attention given to why a patient has not responded and whether it is appropriate to discharge .
I recognise that this consideration, in addition to informing Nearest Relatives of their right to request a MHA, will result in additional burdens for what is an already over-stretched workforce. This may be a matter for the Minister to reflect upon in considering the staffing issue highlighted above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 adapt patient contact methods to known communication needs
Wider context from the report “2) Community Mental Health Team
i) There was a delay of one month in responding to a letter requesting advice from a GP. This was said to be due to staff shortages. At inquest it was noted that, 3.5 years later, staff shortages remain.
I am aware the ICB has made concerted efforts to recruit. This is a concern that appears to require attention from central government and so this point needs addressing by the Secretary of State. I note this is not the first occasion I have written to the Minister to make her aware of the persisting difficulties in recruiting mental health staff in Cornwall and the Isles of Scilly.
ii) A letter requesting advice was treated as a referral (twice.) It was accepted in evidence that there appeared to be confusion on the part of CMHT staff about how to treat a letter from a GP notwithstanding it set out clearly it was a request for advice.
iii) Once the letter from the GP was taken as a request for a referral, attempting to contact the patient by telephone . It was known Jacob was selectively mute and so it should have been readily apparent he was not going to respond . Policy appears to have been followed without consideration of the clinical circumstances .
iv) Discharging a patient’s referral without any clinical judgment. ████████ referral was discharged after he did not answer his phone twice (as he wouldn’t, being mute) or respond to an opt-in letter (that was sent to the wrong address.) The evidence was clear that ████████ lacked insight into his condition and steadfastly refused all offers of support. He was not going to ‘opt-in’ voluntarily. What appeared from the evidence to be a blanket policy of discharging patients who fail to respond (because they are unwell and lack insight) will result in those patients most in need of care being wrongly discharged. In my view, there needs to be some form of triage or clinical attention given to why a patient has not responded and whether it is appropriate to discharge.
I recognise that this consideration, in addition to informing Nearest Relatives of their right to request a MHA, will result in additional burdens for what is an already over-stretched workforce. This may be a matter for the Minister to reflect upon in considering the staffing issue highlighted above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant presentation information with family
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented , notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 recording family-provided clinical timelines
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to advise Nearest Relatives of statutory rights to request MHA assessment
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA . This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inaccurate or incomplete discharge summaries failing to record diagnostic uncertainty
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” 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 statutory guidance for discharge from mental health and learning disability and autism inpatient settings, including patient, carer and family involvement in discharge planning.
Verbatim wording from the response “From a national perspective, we recognise how vital it is that organisations across the health system work together to ensure effective discharge planning and the best outcomes for people who are discharged from hospital, and that people and their chosen carers are fully involved in the process. On 26 January 2024, new statutory guidance for discharge from all mental health and learning disability and autism inpatient settings for children, young people and adults was published. The guidance provides clarity in relation to how health and care systems can work together to support discharge from all mental health inpatient settings and ensure the right support is in place in the community. The guidance also includes best practice on how patients, carers and family members should be involved in discharge planning.” Source location 2024-0267 Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for local mental health service staffing and operations lies with the relevant trust.
Verbatim wording from the response “Turning to your concerns around the impact of staffing shortages on service delivery, the Government is not able to comment on staffing levels locally, as responsibility for the staffing and operations of mental health services lies with the relevant trust. However, we recognise the need to increase workforce capacity in NHS mental health services overall. Nationally, positive progress has been made on growing the mental health workforce which, as at December 2023, had increased by around 20,800 compared to 2019/20. In addition, the NHS Long Term Workforce Plan sets out an ambition to grow the mental health, primary and community care workforce by 73% by 2036–37.” Source location 2024-0267 Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Integrated Care Board is expected to respond to concerns about the specific care provided.
Verbatim wording from the response “I would expect the Cornwall and Isles of Scilly Integrated Care Board to respond in detail to the concerns you have raised about the specifics of the care that Sally’s son received.” Source location 2024-0267 Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Primary care professionals remain responsible for attending relevant safeguarding meetings and transferring patient records between practices promptly.
Verbatim wording from the response “However, ICBs across England should ensure they have in place robust information sharing processes that connect information presented at MASH and other safeguarding meetings with the network of primary care providers. ICBs have dedicated safeguarding and mental health leads who are best placed to set up these processes within their local setting. Primary care professionals themselves remain best placed to attend relevant safeguarding meetings regarding individual cases. Primary care professionals should also work to transfer patient records from one practice to another in a timely way, when a patient registers with a new practice.” Source location 2024-0267 Response from Department of Health and Social Care
Open published response
13 May 2024 Elvon Paul Randolph Morton · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Failure to make and evidence a reasoned decision on rapid tranquilisation View source Failure to document key clinical decisions and treatment stages contemporaneously View source Failure of legal assurance functions to identify absent investigation and remediation evidence View source Failure to escalate and mitigate workload pressure affecting patient safety View source Failure to identify serious incidents and remediate sub-optimal practice View source Inadequacy and siloing of incident reporting and mortality review processes View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elvon Paul Randolph Morton · 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
Elvon Paul Randolph Morton, a 38-year-old man with extensive co-morbidity, was admitted to hospital on 6 December 2022 with abdominal pain, vomiting, diarrhoea, dizziness and shortness of breath. He deteriorated and went into cardiac arrest while awaiting a CT scan under sedation; the inquest concluded that his death was caused by the combined effects of septic shock, oxycodone and lorazepam. Concerns included poor documentation of critical decisions, a flawed decision to sedate him, failures to manage workload pressures safely, and inadequate Trust processes for identifying and reviewing serious incidents.
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 make and evidence a reasoned decision on rapid tranquilisation
Wider context from the report “3. The decision to sedate Mr Morton was flawed. The lack of contemporary documentation impeded an effective coronary investigation and review of that clinical decision. In the absence of clear and reasoned evidence of decision making, weight must be attached to evidence heard that Elvon’s; size, sex and race triggered a heightened response by hospital staff to his agitation, leading to security officers being called. It was in this febrile atmosphere that the decision to utilise rapid tranquilisation, a simpler and faster process than anaesthesia and intubation, was made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to document key clinical decisions and treatment stages contemporaneously
Wider context from the report “1. Documentation of key stages in Mr Morton’s care was poor or non-existent. Critical decisions on; mental capacity, best interests, the choice of sedation, the amount of drug administered, the method of administration and the timing of administration were not clearly recorded. In multi-clinician treatment contemporary documentation is essential to preserve patient safety. In this case the lack of clear documentation meant that some clinicians were unaware that Elvon was sedated, whilst others were ignorant of the fact that he had declined treatment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of legal assurance functions to identify absent investigation and remediation evidence
Wider context from the report “4. A failure in governance at the Trust meant that this case was not identified as a serious incident. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice
Elvon’s relative youth, the unexpected nature of his death, the poor standard of documentation, the effect of patient acuity on the ability of staff to comply with regulatory duties and the Trust’s acceptance (in Feb 2023) that intubation should have been undertaken earlier, should have resulted in this matter being properly reviewed.
In this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and SIRMAP procedure were inadequate. Each structure was siloed from the other, leading to inconsistent findings.
Additionally, despite preparing for an inquest, neither the Trust’s legal team nor external lawyers seemed capable of identifying to the trust the absence of meaningful evidence of investigation, reflection and remediation of practice that was undoubtedly required in this case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate and mitigate workload pressure affecting patient safety
Wider context from the report “2. Witnesses blamed poor documentation on workload, specifically an influx of acute patients into the resuscitation bays. Despite this, no evidence was presented that any attempt was made to mitigate this pressure by, escalating the matter to the site manager , nor did the on-call ED consultant find it necessary to come in to the unit . These actions tend towards a “coping culture” inconsistent with patient safety .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to identify serious incidents and remediate sub-optimal practice
Wider context from the report “4. A failure in governance at the Trust meant that this case was not identified as a serious incident. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice
Elvon’s relative youth, the unexpected nature of his death, the poor standard of documentation, the effect of patient acuity on the ability of staff to comply with regulatory duties and the Trust’s acceptance (in Feb 2023) that intubation should have been undertaken earlier, should have resulted in this matter being properly reviewed.
In this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and SIRMAP procedure were inadequate. Each structure was siloed from the other, leading to inconsistent findings.
Additionally, despite preparing for an inquest, neither the Trust’s legal team nor external lawyers seemed capable of identifying to the trust the absence of meaningful evidence of investigation, reflection and remediation of practice that was undoubtedly required in this case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequacy and siloing of incident reporting and mortality review processes
Wider context from the report “4. A failure in governance at the Trust meant that this case was not identified as a serious incident. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice
Elvon’s relative youth, the unexpected nature of his death, the poor standard of documentation, the effect of patient acuity on the ability of staff to comply with regulatory duties and the Trust’s acceptance (in Feb 2023) that intubation should have been undertaken earlier, should have resulted in this matter being properly reviewed.
In this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and SIRMAP procedure were inadequate. Each structure was siloed from the other, leading to inconsistent findings.
Additionally, despite preparing for an inquest, neither the Trust’s legal team nor external lawyers seemed capable of identifying to the trust the absence of meaningful evidence of investigation, reflection and remediation of practice that was undoubtedly required in this case.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The primarily local concerns are for Barts Health NHS Foundation Trust to address.
Verbatim wording from the response “In preparing this response, Departmental officials have made enquiries with NHS England. The department is advised that the matters of concern raised are primarily local and for Barts Health NHS Foundation Trust to address, who confirm they are in receipt of this report. The report provides a further opportunity for the Trust to reflect and assure itself that it has acted on all the learnings to be taken from Mr Morton’s death. It is vital that lessons are learnt collectively, and changes are made to reflect where things have gone wrong, which is essential to ensure the NHS provides safe, high-quality care.” Source location Response from DHSC
Open published response
8 May 2024 Bobilya Mulonge · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Delays in ambulances clearing Accident and Emergency departments View source Delays in paramedics attending Category 2 calls View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Bobilya Mulonge · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Mulonge became unconscious after developing laboured breathing on 24 November 2022 and was found in cardiac arrest when an ambulance arrived 72 minutes after the call. She died later that day from congestive cardiac failure against a background of hypertensive heart disease, chronic kidney disease and type II diabetes mellitus; the principal concern was that delays in ambulance response times had not been resolved within target ranges because ambulances could not be cleared from Accident and Emergency departments.
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 ambulances clearing Accident and Emergency departments
Wider context from the report “Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges. This is because resources available in the North West Ambulance Service cannot be fully utilised as a result of the delays in ambulances clearing Accident and Emergency departments .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 paramedics attending Category 2 calls
Wider context from the report “Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges . This is because resources available in the North West Ambulance Service cannot be fully utilised as a result of the delays in ambulances clearing Accident and Emergency departments.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £200 million of additional funding to expand ambulance capacity and improve response times.
Verbatim wording from the response “Your report highlights that NWAS were under high demand at the time of the incident. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times.” Source location 2024-0250 Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make £1.6 billion available over two years to support timely and effective hospital discharge and reduce admission waits.
Verbatim wording from the response “To improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans. £1.6 billion of funding was also made available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E.” Source location 2024-0250 Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £1 billion to increase staffed core hospital beds by 5,000 compared with 2022/23 plans.
Verbatim wording from the response “To improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans. £1.6 billion of funding was also made available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E.” Source location 2024-0250 Response from Department of Health and Social Care
Open published response
8 May 2024 Oliver Walter John Stephen BARNETT · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1 Lack of residential substance misuse treatment facilities for children under 18 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Oliver Walter John Stephen BARNETT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Oliver Barnett, aged 17, died on 8 December 2022 from an overdose of illicitly obtained drugs after experiencing drug dependence and previous overdoses. The report identified the absence of residential substance misuse treatment facilities in England for people under 18, leaving children to receive community treatment and placing them at greater risk of relapse and death by overdose.
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 residential substance misuse treatment facilities for children under 18
Wider context from the report “There are no residential substance misuse treatment facilities for children and young persons under the age of 18 in England. If a child is acutely unwell through substance misuse, they will be treated in hospital and then discharged home to receive treatment in the community. Parents/guardians must manage the detoxification programme, and the risk of relapse, supported by substance misuse agencies. There is a disparity between the treatment offered to adults and children, and the absence of residential substance misuse facilities places children at greater risk of relapse and death by overdose .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £532 million in additional funding to local authorities to improve drug and alcohol treatment quality and capacity.
Verbatim wording from the response “Additional funding of £532 million over three years from 2022/23 to 2024/25 has been given to local authorities to improve the quality and capacity of drug and alcohol treatment.” Source location Response from DHSC
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 Community-based treatment and existing alternative residential placements are generally considered more appropriate than dedicated residential rehabilitation for young people.
Verbatim wording from the response “Substance misuse among children and young people typically cooccurs with and compounds other problems and vulnerabilities. Therefore, it is important that links are maintained with their family and positive social networks, as well as other sources of support including child social workers, schools, youth offending teams and mental health services. Differences in emotional and cognitive development, problem awareness and readiness for change, as well as consent and safeguarding issues, all require a different approach and mean that residential rehabilitation is not one that easily translates from adult to young peoples’ service provision.” Source location Response from DHSC
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 Community treatment with clinical and psychosocial support is generally considered appropriate for children requiring detoxification.
Verbatim wording from the response “Having taken advice from my officials, my understanding is that it is rare for detoxification to be clinically appropriate for a child under 18. In instances where it is judged appropriate, as in the case of Oliver, then in line with national clinical guidelines, most cases can be managed in the community with appropriate clinical and psychosocial support provided by community drug and alcohol treatment service in partnership with a local NHS hospital or mental health trust.” Source location Response from DHSC
Open published response
7 May 2024 David RILEY · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 5 Failure to specify and disseminate learning from the DOAC pausing incident View source Failure to coordinate pericardiocentesis timing with the duration of DOAC interruption View source Lack of clear guidance for clinicians on pausing DOACs View source Failure to communicate, recognise and act on time-critical DOAC directions View source Inconsistent understanding and application of DOAC pausing decisions 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
David RILEY · 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
David Riley developed a pericardial effusion after atrial fibrillation ablation and later suffered a stroke before dying on 10 June 2023. Concerns included inconsistent decisions about pausing Apixaban, delays in restarting it, inadequate communication and continuity of care, and difficulties using computerised clinical records.
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 specify and disseminate learning from the DOAC pausing incident
Wider context from the report “Although the Warwick hospital conducted a Root Cause Analysis Investigation Report (RCAIR) of 6 July 2023 which indicated that the pausing of the DOAC was a lesson learned, it did not indicate what was learned . The only further action was limited to the incident being presented at the Grand Round, but this had not taken place at the time of the inquest, some 9 months after publication of the RCAIR . There are remaining outstanding matters of concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate pericardiocentesis timing with the duration of DOAC interruption
Wider context from the report “2. Effective communication
From the evidence, there was a failure to effectively communicate, recognise and act on directions that were time critical, such as restarting the DOAC as directed. It does not appear that there was any consideration as to the timing of the pericardiocentesis to ensure that the DOAC was paused for a short a time as possible . The evidence suggested that this may be due to lack of continuity of care and the difficulties in the way in which computerised clinical/pharmacy records are updated and accessed. Clear communication between medical staff is essential to patient care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance for clinicians on pausing DOACs
Wider context from the report “1. Decisions regarding pausing of DOACs.
It was not clear if there is national guidance available to clinicians regarding the pausing of DOACs and the considerations to be applied in making that decision . If there is such guidance, it is not widely understood or on the evidence given, followed consistently from hospital to hospital or within different teams. The inconsistency of approach appears from the evidence to increase the risk of misunderstanding and to put patients with atrial fibrillation at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate, recognise and act on time-critical DOAC directions
Wider context from the report “2. Effective communication
From the evidence, there was a failure to effectively communicate, recognise and act on directions that were time critical, such as restarting the DOAC as directed . It does not appear that there was any consideration as to the timing of the pericardiocentesis to ensure that the DOAC was paused for a short a time as possible. The evidence suggested that this may be due to lack of continuity of care and the difficulties in the way in which computerised clinical/pharmacy records are updated and accessed. Clear communication between medical staff is essential to patient care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistent understanding and application of DOAC pausing decisions
Wider context from the report “1. Decisions regarding pausing of DOACs.
It was not clear if there is national guidance available to clinicians regarding the pausing of DOACs and the considerations to be applied in making that decision. If there is such guidance, it is not widely understood or on the evidence given, followed consistently from hospital to hospital or within different teams . The inconsistency of approach appears from the evidence to increase the risk of misunderstanding and to put patients with atrial fibrillation at risk .
” 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 responding to concerns about national DOAC guidance lies with NICE, which develops evidence-based NHS guidelines.
Verbatim wording from the response “NICE will be responding directly to your concern about national guidance on DOACs. As you will be aware, the National Institute for Health and Care Excellence (NICE) is an executive non-departmental public body, sponsored by the DHSC. It is the independent body responsible for developing evidence-based guidelines for the National Health Service, following a rigorous process and extensive engagement with stakeholders and expert input to develop the scope of the guidelines. However, it is important to note that NICE guidelines do not override a clinician’s responsibility to make decisions appropriate to individual patients. NICE guidelines describe best practice, and the Government expects NHS commissioners to take them into account in designing services that meet the needs of their local populations.” Source location Response from DHSC
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 Operational responsibility for delivering health services and responding to related concerns lies with NHS England.
Verbatim wording from the response “NHS England is operationally responsible for delivering health services across the country and will be responding directly to your concerns at length. NHS England is an executive non-departmental public body, sponsored by the Department of Health and Social Care.” Source location Response from DHSC
Open published response
1 May 2024 Jordan George James Fogg Howarth · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 8 Lack of joint clinical decision-making about withholding antibiotics View source Lack of multidisciplinary assessment of complex patient cases View source Failure to refer patients with a NEWS2 score of 5 and no ceiling of care to the CC Outreach team View source Unclear responsibility for continuity of care View source Failure of senior nursing staff to identify missed CC Outreach referrals View source Failure to document the ICU consultant’s rationale for examination and admission decisions View source Failure to put alternative treatments in place when antibiotics are withheld View source Failure to document consultant clinical discussions View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jordan George James Fogg Howarth · 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
Jordan George James Fogg Howarth, a fit and healthy 25-year-old, was admitted to hospital on 3 April 2023 with an unexplained and deteriorating condition. He was not escalated for critical care review as required, and although a later review identified that he needed urgent ICU admission, this was delayed; he suffered a cardiac arrest on 6 April 2023 and could not be resuscitated. The principal concerns included inadequate coordination and continuity of care, failure to follow escalation policy, insufficient documentation of clinical decisions, and a lack of multidisciplinary discussion.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of joint clinical decision-making about withholding antibiotics
Wider context from the report “1. The inquest heard evidence that whilst there was input into Jordan’s care from both the microbiologist and the consultant physician there was not a joint approach to his care and no detailed discussions regarding the decision to withhold antibiotics . The inquest was told that this decision was reached by the microbiology team and as a consequence, antibiotics were withheld without further alternative treatments being put in place despite how unwell he was and despite the fact that the treating clinicians were unclear about the cause of his deterioration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of multidisciplinary assessment of complex patient cases
Wider context from the report “5. The inquest heard that despite the complexity of his case there was no evidence of a multi-disciplinary discussion/approach to assess his position fully and that it was unclear who was responsible for the continuity of his care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to refer patients with a NEWS2 score of 5 and no ceiling of care to the CC Outreach team
Wider context from the report “2. In relation to ICU the evidence before the inquest was that the Critical Care Outreach Practitioner had identified that Jordan needed to be moved to ICU urgently. This view had then to be ratified by the ICU Consultant if he was to be accepted into ICU. There was no documentation from the ICU consultant setting out their rationale for not examining Jordan at that point and for declining to admit him at that point. All the documentation was in the Critical Care Practitioner’s notes. There was no evidence of any discussions between the medical consultant and the ICU consultant about the decision in the clinical notes.
3. The trust policy was that anyone who had a NEWS2 score of 5 and no ceiling of care should be referred to the CC Outreach team . The inquest heard evidence that this was not followed on a number of occasions and the fact it had been missed was not identified by more senior members of the nursing team.
4. The inquest heard oral evidence of conversations that it was told had taken place between consultants in a number of specialisms about Jordan. These were not documented in his notes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for continuity of care
Wider context from the report “5. The inquest heard that despite the complexity of his case there was no evidence of a multi-disciplinary discussion/approach to assess his position fully and that it was unclear who was responsible for the continuity of his care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of senior nursing staff to identify missed CC Outreach referrals
Wider context from the report “2. In relation to ICU the evidence before the inquest was that the Critical Care Outreach Practitioner had identified that Jordan needed to be moved to ICU urgently. This view had then to be ratified by the ICU Consultant if he was to be accepted into ICU. There was no documentation from the ICU consultant setting out their rationale for not examining Jordan at that point and for declining to admit him at that point. All the documentation was in the Critical Care Practitioner’s notes. There was no evidence of any discussions between the medical consultant and the ICU consultant about the decision in the clinical notes.
3. The trust policy was that anyone who had a NEWS2 score of 5 and no ceiling of care should be referred to the CC Outreach team. The inquest heard evidence that this was not followed on a number of occasions and the fact it had been missed was not identified by more senior members of the nursing team .
4. The inquest heard oral evidence of conversations that it was told had taken place between consultants in a number of specialisms about Jordan. These were not documented in his notes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to document the ICU consultant’s rationale for examination and admission decisions
Wider context from the report “2. In relation to ICU the evidence before the inquest was that the Critical Care Outreach Practitioner had identified that Jordan needed to be moved to ICU urgently. This view had then to be ratified by the ICU Consultant if he was to be accepted into ICU. There was no documentation from the ICU consultant setting out their rationale for not examining Jordan at that point and for declining to admit him at that point . All the documentation was in the Critical Care Practitioner’s notes. There was no evidence of any discussions between the medical consultant and the ICU consultant about the decision in the clinical notes.
3. The trust policy was that anyone who had a NEWS2 score of 5 and no ceiling of care should be referred to the CC Outreach team. The inquest heard evidence that this was not followed on a number of occasions and the fact it had been missed was not identified by more senior members of the nursing team.
4. The inquest heard oral evidence of conversations that it was told had taken place between consultants in a number of specialisms about Jordan. These were not documented in his notes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to put alternative treatments in place when antibiotics are withheld
Wider context from the report “1. The inquest heard evidence that whilst there was input into Jordan’s care from both the microbiologist and the consultant physician there was not a joint approach to his care and no detailed discussions regarding the decision to withhold antibiotics. The inquest was told that this decision was reached by the microbiology team and as a consequence, antibiotics were withheld without further alternative treatments being put in place despite how unwell he was and despite the fact that the treating clinicians were unclear about the cause of his deterioration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to document consultant clinical discussions
Wider context from the report “2. In relation to ICU the evidence before the inquest was that the Critical Care Outreach Practitioner had identified that Jordan needed to be moved to ICU urgently. This view had then to be ratified by the ICU Consultant if he was to be accepted into ICU. There was no documentation from the ICU consultant setting out their rationale for not examining Jordan at that point and for declining to admit him at that point. All the documentation was in the Critical Care Practitioner’s notes. There was no evidence of any discussions between the medical consultant and the ICU consultant about the decision in the clinical notes.
3. The trust policy was that anyone who had a NEWS2 score of 5 and no ceiling of care should be referred to the CC Outreach team. The inquest heard evidence that this was not followed on a number of occasions and the fact it had been missed was not identified by more senior members of the nursing team.
4. The inquest heard oral evidence of conversations that it was told had taken place between consultants in a number of specialisms about Jordan. These were not documented in his notes.
” 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, implement and spread the PIER Framework to support staff managing physical deterioration and involve patients, families and carers.
Verbatim wording from the response “Implementation of Martha’s Rule forms part of NHS England’s Managing Deterioration Safety Improvement Programme. This programme aims to reduce deterioration-associated harm by improving the prevention, identification, escalation and response to physical deterioration, through better system co-ordination and as part of safe and reliable pathways of care. In addition to phase one of Martha’s Rule implementation, the programme consists of the following workstreams:” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The hospital is responsible for considering the operational concerns and reporting the actions and improvements it will take.
Verbatim wording from the response “Most of these issues are operational in nature and I note that you have rightly sent your report to the hospital in question (Tameside General Hospital). It will be important that they consider these issues and findings fully and write to you with the actions and improvements they will be taking to address your findings and prevent a recurrence of what happened to Mr Howarth.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 2 Delays in offloading ambulance patients at hospitals View source Failure to provide ambulance responses within the required 40 minutes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sophie HINDMARSH · 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
Sophie HINDMARSH had complex needs and required full-time care. After her father called 999 because she was vomiting brown liquid, felt hot to the touch and had a leaking feeding tube, the ambulance arrived 4 hours and 46 minutes after the call; concerns centred on delays in ambulance response and hospital handovers that reduced available ambulance resources.
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 offloading ambulance patients at hospitals
Wider context from the report “The ambulance service was called at 0245 on 21 July 2022 and the call was coded as a Category 2 at 0251 call requiring a response within 40 minutes. The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call.
There was a significant delay in offloading patients at hospitals which tied up ambulance resource on that day and meant they were unable to respond to emergency calls .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 ambulance responses within the required 40 minutes
Wider context from the report “The ambulance service was called at 0245 on 21 July 2022 and the call was coded as a Category 2 at 0251 call requiring a response within 40 minutes . The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call .
There was a significant delay in offloading patients at hospitals which tied up ambulance resource on that day and meant they were unable to respond to emergency calls.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £200 million in additional funding to ambulance trusts to expand capacity and improve response times.
Verbatim wording from the response “Your report highlights that YAS were under high demand at the time of the incident. To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make £1.6 billion available over two years to support timely hospital discharge and reduce admission waits from A&E.
Verbatim wording from the response “£1.6 billion of funding was also made available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £1 billion in dedicated funding to increase staffed core hospital beds by 5,000 and improve patient flow and bed capacity.
Verbatim wording from the response “Your report highlights that YAS were under high demand at the time of the incident. To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans.” Source location Response from DHSC
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 Specific actions to improve ambulance response and hospital handover times will be provided directly by NHS England and the Integrated Care Board.
Verbatim wording from the response “Your report raised concerns about ambulance response times by Yorkshire Ambulance Service NHS Trust (YAS) and hospital handover delays. You have appropriately shared your report and concerns with West Yorkshire Integrated Care Board and NHS England (NHSE). Departmental officials have made enquiries with NHSE and West Yorkshire Integrated Care Board who I understand will be writing to you directly on the specific actions being taken locally to improve ambulance response and handover times.” Source location Response from DHSC
Open published response
26 Apr 2024 Charlie Millers · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Ineffective investigations due to inadequate investigator training and understanding of complex health processes and procedures View source Lack of oversight of previous concerns and their rectification View source Lack of independent investigation of deaths of patients detained under the Mental Health Act 1983 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Charlie Millers · 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
Charlie Millers was detained under the Mental Health Act and was found in his room with a ligature after returning from home leave; he died five days later in hospital. The report raises concerns about whether required observations were carried out and documented, and about the effectiveness and independence of investigations into such deaths. It also identifies a lack of oversight across previous concerns and investigations.
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 Ineffective investigations due to inadequate investigator training and understanding of complex health processes and procedures
Wider context from the report “2. In addition the Investigations which are currently being undertaken are ineffective either due to a lack of trained, investigators who conduct internal reviews or a lack of understanding of complex health processes and procedures .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of oversight of previous concerns and their rectification
Wider context from the report “1. Deaths of patients detained under the Mental Health Act 1983 are not subject to any independent investigation in the same way as deaths in police custody (Independent Office Police Complaints) or in Prison (Prison and Probation Ombudsman). As a result, investigations are not effective, no single body has oversight of previous concerns and how these were going to be rectified by the organisation . Therefore critical learning and evidence is being lost which may prevent future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of independent investigation of deaths of patients detained under the Mental Health Act 1983
Wider context from the report “1. Deaths of patients detained under the Mental Health Act 1983 are not subject to any independent investigation in the same way as deaths in police custody (Independent Office Police Complaints) or in Prison (Prison and Probation Ombudsman). As a result, investigations are not effective, no single body has oversight of previous concerns and how these were going to be rectified by the organisation. Therefore critical learning and evidence is being lost which may prevent future deaths.
” 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 Roll out the statutory medical examiner system to provide independent scrutiny of non-coronial deaths across England and Wales.
Verbatim wording from the response “Finally, a new statutory medical examiner system is being rolled out across England and Wales to provide independent scrutiny of deaths, and to give bereaved people a voice. From 9 September 2024 all deaths in any health setting that are not investigated by a coroner will be reviewed by NHS medical examiners. Medical examiners are senior medical doctors who are contracted for a number of sessions a week to provide independent scrutiny of the causes of death, outside their usual clinical duties. They are trained in the legal and clinical elements of death certification processes.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Providers are responsible for meeting national patient-safety incident-response standards and quality-assuring learning outputs.
Verbatim wording from the response “NHS England has recognised that the Serious Incident Framework required improvements in relation to learning from incidents. The introduction of the Patient Safety Incident Response Framework in 2022 represents a significant shift in the way the NHS responds to patient safety incidents increasing the focus on how incidents happen and the factors that contribute for the purpose of learning and improving patient safety. It is the responsibility of providers to ensure their organisation meets national patient safety incident response standards, to ensure the Framework is central to overarching safety governance arrangements and quality assure learning response outputs.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 3 Lack of awareness of hyponatremia developing in birthing women View source Failure to recognise the risk of hyponatremia when giving intravenous fluids View source Failure to keep accurate records of fluid input and output 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
Orlando NOVA DAVIS · 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
Orlando Nova DAVIS suffered an irreversible brain injury after his mother developed unrecognised hyponatremia and seizures during labour, restricting oxygen before his birth. He died aged 14 days on 24 September 2021; the principal concerns were a lack of recognition and understanding of hyponatremia among midwives and clinicians, and inaccurate recording of fluid input and output despite additional fluids being given.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of hyponatremia developing in birthing women
Wider context from the report “Orlando was caused an irreversible brain injury when his mother suffered a seizure having developed hyponatremia during her labour. The concern is that the midwifes (in the community and in the hosptial, who had cared for Orlando’s mother) were completely unaware of this potential condition developing in birthing women .
In this case due to Orlando developing a tachicardia during labour Orlando’s mothers was actively encouraged to take in more fluid yet there was no accurate record kept of either input or output of fluid. Again when in hospital further fluids were given intravenously with no recognition of any potential risk of hyponatremia developing by the midwives or the Doctor on duty.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the risk of hyponatremia when giving intravenous fluids
Wider context from the report “Orlando was caused an irreversible brain injury when his mother suffered a seizure having developed hyponatremia during her labour. The concern is that the midwifes (in the community and in the hosptial, who had cared for Orlando’s mother) were completely unaware of this potential condition developing in birthing women.
In this case due to Orlando developing a tachicardia during labour Orlando’s mothers was actively encouraged to take in more fluid yet there was no accurate record kept of either input or output of fluid. Again when in hospital further fluids were given intravenously with no recognition of any potential risk of hyponatremia developing by the midwives or the Doctor on duty .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 keep accurate records of fluid input and output
Wider context from the report “Orlando was caused an irreversible brain injury when his mother suffered a seizure having developed hyponatremia during her labour. The concern is that the midwifes (in the community and in the hosptial, who had cared for Orlando’s mother) were completely unaware of this potential condition developing in birthing women.
In this case due to Orlando developing a tachicardia during labour Orlando’s mothers was actively encouraged to take in more fluid yet there was no accurate record kept of either input or output of fluid . Again when in hospital further fluids were given intravenously with no recognition of any potential risk of hyponatremia developing by the midwives or the Doctor on duty.
” Open source report
25 Apr 2024 Richard Carpenter · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 4 Failure to consistently meet ambulance response targets View source Lack of sufficient free hospital beds due to bed blocking View source Lack of appropriate community care packages for patients fit for discharge View source Delays in ambulance handover at hospitals 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
Richard Carpenter · 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
Richard Carpenter underwent major cardiac surgery on 19 November 2021 and was discharged home on 28 November. After developing increasing left-sided pain late on 30 November, he became unresponsive and died at home at 05:00 on 1 December 2021, following a postoperative bleed. The principal concern was that delays in Category 2 ambulance responses, linked in part to hospital bed shortages and delayed discharges, could increase the risk of otherwise preventable deaths, although no causal link was found between the delay and Richard’s 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 consistently meet ambulance response targets
Wider context from the report “The reason I am submitting this Regulation 28 Report is that I heard evidence when I put the question to ████████ as to whether or not the Trust is hitting its targets in relation to ambulance response, and I was told that the Trust was not meeting those targets consistently in a way comparing to pre-pandemic times. When I drilled down further as to where problems lay, again the issue of patients in hospitals taking up beds arose in circumstances whereby the patient was physically fit for discharge but they were not able to be discharged due to the lack of appropriate care packages in the community. This issue has arisen in other Regulation 28 Reports that I have written to you recently and I am concerned as regards the lack of availability of sufficient free beds in hospital due to bed blocking is still causing significant disruption to ambulance services trying to transfer patients to hospital. Although on this occasion I did not find a causal link between the delay and Richard’s death, I am concerned that delays in ambulances attending patients in the community are likely to increase the risk of death in Cat 2 instances especially that would otherwise be preventable had the patient been got to hospital in a timely fashion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficient free hospital beds due to bed blocking
Wider context from the report “The reason I am submitting this Regulation 28 Report is that I heard evidence when I put the question to ████████ as to whether or not the Trust is hitting its targets in relation to ambulance response, and I was told that the Trust was not meeting those targets consistently in a way comparing to pre-pandemic times. When I drilled down further as to where problems lay, again the issue of patients in hospitals taking up beds arose in circumstances whereby the patient was physically fit for discharge but they were not able to be discharged due to the lack of appropriate care packages in the community. This issue has arisen in other Regulation 28 Reports that I have written to you recently and I am concerned as regards the lack of availability of sufficient free beds in hospital due to bed blocking is still causing significant disruption to ambulance services trying to transfer patients to hospital . Although on this occasion I did not find a causal link between the delay and Richard’s death, I am concerned that delays in ambulances attending patients in the community are likely to increase the risk of death in Cat 2 instances especially that would otherwise be preventable had the patient been got to hospital in a timely fashion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate community care packages for patients fit for discharge
Wider context from the report “The reason I am submitting this Regulation 28 Report is that I heard evidence when I put the question to ████████ as to whether or not the Trust is hitting its targets in relation to ambulance response, and I was told that the Trust was not meeting those targets consistently in a way comparing to pre-pandemic times. When I drilled down further as to where problems lay, again the issue of patients in hospitals taking up beds arose in circumstances whereby the patient was physically fit for discharge but they were not able to be discharged due to the lack of appropriate care packages in the community . This issue has arisen in other Regulation 28 Reports that I have written to you recently and I am concerned as regards the lack of availability of sufficient free beds in hospital due to bed blocking is still causing significant disruption to ambulance services trying to transfer patients to hospital. Although on this occasion I did not find a causal link between the delay and Richard’s death, I am concerned that delays in ambulances attending patients in the community are likely to increase the risk of death in Cat 2 instances especially that would otherwise be preventable had the patient been got to hospital in a timely fashion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover at hospitals
Wider context from the report “During the course of the Inquest I heard evidence from the Southwest Ambulance Trust from ████████ who is the Deputy Head of Clinical Operations in Safety and he explained in detail the pressures that all ambulance trusts were under at that particular time and he also explained new ways of working with a view to reducing the number of outstanding unallocated calls including the use of the National Model for Clinical Navigation and the use of ambulance personnel at hospital in an attempt to free up ambulances although I did hear that it is not uncommon for around 30% of available ambulances to still be held up at hospitals in our area waiting for a handover .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £200 million in additional funding to ambulance trusts to expand capacity and improve response times.
Verbatim wording from the response “Your report highlights that SWAST were responding to high demand. To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £1 billion through the Discharge Fund to commission discharge care packages and improve discharge processes.
Verbatim wording from the response “£1 billion was invested this year through the Discharge Fund in commissioning packages of care for people being discharged and improving discharge processes. A £40 million fund was also launched in September 2023 for local authorities in areas with the greatest challenges on urgent and emergency care. Local authorities used this funding for social care provision and strengthening admissions avoidance and discharge services over the past winter. The number of people discharged from hospital with packages of health and social care support has increased by 9% from the end of March 2023 to the end of March 2024.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch a £40 million fund for local authorities facing significant urgent and emergency care pressures.
Verbatim wording from the response “£1 billion was invested this year through the Discharge Fund in commissioning packages of care for people being discharged and improving discharge processes. A £40 million fund was also launched in September 2023 for local authorities in areas with the greatest challenges on urgent and emergency care. Local authorities used this funding for social care provision and strengthening admissions avoidance and discharge services over the past winter. The number of people discharged from hospital with packages of health and social care support has increased by 9% from the end of March 2023 to the end of March 2024.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £1 billion to increase staffed core hospital beds by 5,000 compared with 2022/23 plans.
Verbatim wording from the response “Your report highlights that SWAST were responding to high demand. To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation SWAST is best placed to determine and implement local action with NHS partners to reduce handover delays and improve ambulance response times.
Verbatim wording from the response “You have appropriately shared your report and concerns with SWAST, who are best placed to respond on the specific action they are taking locally with NHS system partners to reduce handover delays and improve ambulance response times.” Source location Response from Department of Health and Social Care
Open published response
23 Apr 2024 Nuliyati BUSINJE · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 3 Failure of the DVT risk assessment tool to assess patients at risk despite no significantly reduced mobility View source Failure to factor psychiatric-unit patients’ increased DVT risk into risk assessment and guidance View source Lack of training and awareness that clot-related abnormal observations can normalise View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nuliyati BUSINJE · 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
Nuliyati Businje was an inpatient on a psychiatric unit when, after abnormal observations and worsening hyperglycaemia during her admission, she suffered a cardiac arrest. Post-mortem examination found a massive pulmonary embolus due to deep venous thrombosis. The concerns included limitations in VTE risk assessment for patients with risk factors other than reduced mobility, insufficient recognition of increased DVT risk among psychiatric inpatients, and inadequate awareness of how clot-related observations may normalise.
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 the DVT risk assessment tool to assess patients at risk despite no significantly reduced mobility
Wider context from the report “1. Despite evidence to suggest that mobility is not the ultimate deciding factor of risk of DVT, the risk assessment tool as currently drafted and relied upon by clinicians would suggest that there is no further need for assessment . This raises a risk of future deaths for those patients such as Ms Businje who were at risk of VTE, or those with cancer for example, but who do not have significantly reduced mobility and would therefore fall outside of the risk assessment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to factor psychiatric-unit patients’ increased DVT risk into risk assessment and guidance
Wider context from the report “2. Based on the evidence I heard, patients on a psychiatric unit are at increased risk of DVT but this is not factored into the risk assessment, nor the NICE guidance . The latter guidance has a specific section for psychiatric patients but does not provide any specific information as to risk and directs the reader to the same Department of Health risk assessment 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 Lack of training and awareness that clot-related abnormal observations can normalise
Wider context from the report “3. Based on the evidence of the expert physician, a common presentation of a clot can be a derangement in observations such as respiratory rate and heart rate, but these can normalise as the clot furthers on and the blockage eases. I am concerned that this does not appear to be widely known , is not part of training at least in the Trust in this case due to the lack of awareness , and I am told is not something which is taught nationally . There is a risk that a clinician without this knowledge would, as in this case, be reassured by the improving observations and the clot, and risk of a further more serious clot, would be overlooked .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with NHS England to consider the VTE risk assessment tool in light of the concerns raised.
Verbatim wording from the response “It is recognised that inpatients on psychiatric wards may be at higher risk of venous thromboembolism due to reduced mobility, poor fluid intake, restraint, catatonia, sedation and antipsychotic use. NICE’s guidance on Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism (NG89) makes clear that all acute psychiatric patients should be assessed to identify VTE and bleeding risk on admission, using a risk assessment tool. The Department will work with NHS England to consider the VTE risk assessment tool, in light of the concerns you have raised.” Source location Response from DHSC
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 NICE, as an independent body, is responsible for reviewing its current guidance and deciding whether updates are needed.
Verbatim wording from the response “I note that you have also written directly to NICE. As NICE is an independent body, it will be for NICE to review its current guidance to see if any updates are needed and I would expect that NICE will want to take your concerns into account as part of this process.” Source location Response from DHSC
Open published response
23 Apr 2024 Ronald Henry SPENCER · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to maintain sufficient staffing for timely patient medical care View source Inadequate cohesive planning for short-term staffing pressures and longer-term solutions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ronald Henry SPENCER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ronald Henry Spencer had an oesophageal stent placed on 13 November 2023, which migrated into the small bowel and caused a suspected bowel perforation. He underwent surgery to remove the stent and repair the bowel, initially recovered, then deteriorated and died on 2 December 2023. The report raised concerns about significant staffing issues and resulting delays in treatment, as well as inadequate cohesive planning for short- and long-term staffing pressures; it stated there was no direct evidence that the delays caused or contributed to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain sufficient staffing for timely patient medical care
Wider context from the report “1. I heard evidence that there were significant staffing issues during the Ronald's period of in-patient care that caused delays to his treatment . Whilst there was no direct evidence at the inquest that these delays caused or contributed to death, any delays in patients receiving medical care due to a lack of staff clearly presents a risk of future deaths occurring.
2. It is recognised that the reasons for delay can be multifactorial, with so called "winter pressures" causing an influx of ill patients and heightened staff absences. "Winter pressures" are now a regular annual event and put significant strain on the NHS. There can be no doubt that patients have died, and will continue to die, from avoidable deaths due to delays caused by these staffing inadequacies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 cohesive planning for short-term staffing pressures and longer-term solutions
Wider context from the report “5. I remain significantly concerned not only that delays are continuing and that deaths will continue to occur into the future, but also that there is inadequate cohesive forward thinking or planning either in relation short term pressures (eg. "winter pressures") or with a view to finding longer term solutions .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £200 million in additional funding to expand ambulance service capacity and improve response times.
Verbatim wording from the response “To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £1 billion in dedicated funding to increase staffed core hospital beds by 5,000 compared with 2022/23 plans.
Verbatim wording from the response “To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for delivering the long-term workforce strategy rather than the responding department undertaking further workforce planning.
Verbatim wording from the response “The NHS Long Term Workforce Plan (LTWP) sets out the steps the NHS and its partners need to take to deliver an NHS workforce that meets the changing needs of the population over the next 15 years.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trusts are responsible for ensuring safe staffing levels in the current day-to-day operation of their hospitals.
Verbatim wording from the response “These actions will aim to close anticipated staffing shortfalls in the NHS in the long term, however Trusts have a responsibility to ensure safe staffing levels in the current day to day operation of their hospitals. This is in line with Care Quality Commission (CQC) Regulation 18 which states that providers must deploy enough suitably qualified, competent and experienced staff to enable them to meet all other regulatory requirements.” Source location Response from Department of Health and Social Care
Open published response
17 Apr 2024 Margaret Avril Burman · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 2 Lack of appropriate community care causing medically fit patients to remain on hospital wards View source Insufficient staffing and resources for falls mitigation on hospital wards View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Margaret Avril Burman · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Margaret Avril Burman, who preferred to be known as Avril, died on 13 July 2021 after an unwitnessed fall at Salisbury District Hospital caused a head injury and intracranial bleed. The report raises concerns that falls risk assessments and enhanced care arrangements were inadequate, and that staffing shortages meant no Healthcare Assistant was available to monitor the ward bay. It also identifies a broader concern that elderly hospital patients remain at significant risk of traumatic and fatal falls because appropriate falls mitigation measures are unavailable.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate community care causing medically fit patients to remain on hospital wards
Wider context from the report “As I have previously indicated in a Regulation 28 Report submitted to you (Raymond Eggleton dated 17th November 2023 which remains unanswered by you) (Department of Health) falls in the hospital environment do not happen, however, as of the view in Avril’s case that had there been an appropriate Healthcare Assistant present then Avril’s fall and death more likely than not would have been avoided.
During the course of the Inquest, I heard evidence from the Hospital’s Falls Specialist, ████████ who indicated that whilst staffing issues have improved there remains a difficulty ensuring appropriate staffing especially when responding to the ever-changing needs on wards where they are occupied by people at risk of falls. She explained to me that in relation to 2 wards in particular, one of which included Spire Ward which is a general geriatric surgical ward and the other which is a trauma and orthopaedic ward, both of which can take approximately 30 patients, that having conducted her own analysis it is transpired that of those admitted onto both those wards that approximately 80% either had a history of falls or the reason for their admission related to a fall. Of those at risk of a fall where the enhanced care toolkit had been deployed, she told me that 70% of those at falls risk required and warranted 1 to 1 support. Generally, these wards have a nursing ratio of between 1 to 8 patients or sometimes 1 to 6 patients with appropriate Healthcare Assistant support. As you can see in relation to a ward of 30 patients, a situation starts to present itself where the majority of personnel on the ward are not providing nursing support but are providing 1 to 1 falls mitigation support, and there simply are not the resources available to provide such cover. As a consequence, where there is an identifiable falls risk, the situation arises and continues at the moment where those patients are not being appropriately safeguarded against the risk of falls on wards. Especially where patients have conditions such as Dementia and Alzheimer’s it can sometimes be the case that it only takes a relatively minor collapse to cause a significant head trauma that leads to death.
The position is further compounded by the fact that I was told the hospital is confronted with the additional problem that it can have up to 70% of those patients on these 2 wards being in a condition where they are medically stabilised and fit to be discharged but due to lack of appropriate care in the community they are remaining on the wards . The longer they remain on the wards the greater the risk of falls especially if they are medically stabilised when in such circumstances, they are more likely to be mobile.
I asked ████████ as to how she thought that improvements could be made and she indicated to me in her evidence that she was of the view that there should be national leadership and a standardised toolkit when assessing falls risks on hospital wards and that there should also be a greater degree of sharing of learning where methods of good practice have been adopted by other Trusts that could easily be adopted by Trusts where this is a challenge.
As I indicated in Mr Eggleton’s Regulation 28 Report, the problem here is multifactorial but as it remains at the moment, I am concerned that the elderly on hospital wards are at significant risk of sustaining a traumatic and fatal injury by having a fall on a ward due to the unavailability of appropriate and necessary falls mitigation measures.
The resolution of this problem is not about the amount of money or the increase in money that is injected into the National Health Service and my concern is that a more strategic approach is required. More money may well indeed be injected into the National Health Service but with inflation as it has been and with wage rises that have taken place in real terms the increase maybe small and the reality is that in real terms it may amount to a reduction in what can be purchased with that money.
The commitment to provide 5000 extra “core” beds to deal with increasing demand is only going to add to the concern unless this issue is addressed.
As I have stated in my last Regulation 28 Report dealing with this issue, the problem is multifactorial, but it is a solution in respect of which the government undoubtedly has a crucial and essential role to play.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 staffing and resources for falls mitigation on hospital wards
Wider context from the report “As I have previously indicated in a Regulation 28 Report submitted to you (Raymond Eggleton dated 17th November 2023 which remains unanswered by you) (Department of Health) falls in the hospital environment do not happen, however, as of the view in Avril’s case that had there been an appropriate Healthcare Assistant present then Avril’s fall and death more likely than not would have been avoided.
During the course of the Inquest, I heard evidence from the Hospital’s Falls Specialist, ████████ who indicated that whilst staffing issues have improved there remains a difficulty ensuring appropriate staffing especially when responding to the ever-changing needs on wards where they are occupied by people at risk of falls . She explained to me that in relation to 2 wards in particular, one of which included Spire Ward which is a general geriatric surgical ward and the other which is a trauma and orthopaedic ward, both of which can take approximately 30 patients, that having conducted her own analysis it is transpired that of those admitted onto both those wards that approximately 80% either had a history of falls or the reason for their admission related to a fall. Of those at risk of a fall where the enhanced care toolkit had been deployed, she told me that 70% of those at falls risk required and warranted 1 to 1 support. Generally, these wards have a nursing ratio of between 1 to 8 patients or sometimes 1 to 6 patients with appropriate Healthcare Assistant support. As you can see in relation to a ward of 30 patients, a situation starts to present itself where the majority of personnel on the ward are not providing nursing support but are providing 1 to 1 falls mitigation support, and there simply are not the resources available to provide such cover . As a consequence, where there is an identifiable falls risk, the situation arises and continues at the moment where those patients are not being appropriately safeguarded against the risk of falls on wards . Especially where patients have conditions such as Dementia and Alzheimer’s it can sometimes be the case that it only takes a relatively minor collapse to cause a significant head trauma that leads to death.
The position is further compounded by the fact that I was told the hospital is confronted with the additional problem that it can have up to 70% of those patients on these 2 wards being in a condition where they are medically stabilised and fit to be discharged but due to lack of appropriate care in the community they are remaining on the wards. The longer they remain on the wards the greater the risk of falls especially if they are medically stabilised when in such circumstances, they are more likely to be mobile.
I asked ████████ as to how she thought that improvements could be made and she indicated to me in her evidence that she was of the view that there should be national leadership and a standardised toolkit when assessing falls risks on hospital wards and that there should also be a greater degree of sharing of learning where methods of good practice have been adopted by other Trusts that could easily be adopted by Trusts where this is a challenge.
As I indicated in Mr Eggleton’s Regulation 28 Report, the problem here is multifactorial but as it remains at the moment, I am concerned that the elderly on hospital wards are at significant risk of sustaining a traumatic and fatal injury by having a fall on a ward due to the unavailability of appropriate and necessary falls mitigation measures .
The resolution of this problem is not about the amount of money or the increase in money that is injected into the National Health Service and my concern is that a more strategic approach is required. More money may well indeed be injected into the National Health Service but with inflation as it has been and with wage rises that have taken place in real terms the increase maybe small and the reality is that in real terms it may amount to a reduction in what can be purchased with that money.
The commitment to provide 5000 extra “core” beds to deal with increasing demand is only going to add to the concern unless this issue is addressed.
As I have stated in my last Regulation 28 Report dealing with this issue, the problem is multifactorial, but it is a solution in respect of which the government undoubtedly has a crucial and essential role to play.
” 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 responding to the report’s concerns rests with NHS England, so no duplicate response will be provided.
Verbatim wording from the response “I am aware that that the National Medical Director is responding to your report on behalf of NHS England and as such I do not intend to duplicate the contents of his communication with you. However, I am assured that NHS England have reflected upon the concerns raised in your report in relation to Ms Burman’s care.” Source location Response from DHSC
Open published response
17 Apr 2024 Jade Marie GRIFFITHS-JONES · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to meet target ambulance response times View source Delays in hospital handover compromising ambulance crew availability View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jade Marie GRIFFITHS-JONES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jade Marie Griffiths-Jones died in hospital on 4 June 2023 after suffering a cardiac arrest caused by coronary artery disease and sustaining severe hypoxic brain injury. An ambulance was not available to attend her earlier chest-pain call within target times, with concerns about ambulance response delays linked to increased demand and hospital handover delays.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to meet target ambulance response times
Wider context from the report “1. During the inquest evidence was given on behalf of West Midlands Ambulance Service from ████████, Learning Response Lead, that at the time of Jade's initial call reporting centralised chest pain at 13:33 on the 31st May 2023 the Trust was experiencing increased volume of calls and significant hospital delays and therefore could not resource the category 2 disposition within national target times (mean average of 18 minutes, 90th centile of 40 minutes). The call was still unresourced when she was reported to be in cardiac arrest during a further call at 15:01 (the 4th call). The Trust's Gold Dashboard that was captured closest to the clock start time for the first call (captured at 13:00:32) identified that there were delays in the mean and 90th percentile response times for Category 1, 2, 3 calls . There was 3 available ambulance resource within the sector at that point in time with 54 Category 2 and 43 Category 3 cases awaiting resource allocation, and 16 cases yet to be prioritised. There were regional hospital delays of up to 218 minutes.
2. For the 2 hours before Jade's call the Birmingham sector had been experiencing a 2 hour spike in demand. However, the real problem affecting resourcing was pandemic crews being stuck at hospitals awaiting handover. In 2023 to 2024 West Midlands Ambulance Service lost approximately 250,000 response hours due to delays at hospitals.
3. West Midlands Ambulance Service have taken a broad range of measures in recent years to tackle increasing response times including measures to reduce call demand through public education, to avert calls away from ambulance services and hospitals via clinical validation, to improve patient flow through intelligent conveying and to increase the number of resources in operation. Aside from seeking funding to recruit further paramedics and increase ambulance numbers alongside continued monitoring and learning there is nothing West Midlands Ambulance Service can identify that they can do to improve the situation further.
4. West Midlands Ambulance Service continue to fail to meet target response times and have been made the subject of a regulation 12 notice on this topic by the CQC.
5. The evidence of West Midlands Ambulance Service is that if hospital handover delays didn’t exist they would be likely to be meeting their response targets as they did before hospital delays became chronic.
In the circumstances it is my conclusion that the availability of ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in hospital handover compromising ambulance crew availability
Wider context from the report “1. During the inquest evidence was given on behalf of West Midlands Ambulance Service from ████████, Learning Response Lead, that at the time of Jade's initial call reporting centralised chest pain at 13:33 on the 31st May 2023 the Trust was experiencing increased volume of calls and significant hospital delays and therefore could not resource the category 2 disposition within national target times (mean average of 18 minutes, 90th centile of 40 minutes). The call was still unresourced when she was reported to be in cardiac arrest during a further call at 15:01 (the 4th call). The Trust's Gold Dashboard that was captured closest to the clock start time for the first call (captured at 13:00:32) identified that there were delays in the mean and 90th percentile response times for Category 1, 2, 3 calls. There was 3 available ambulance resource within the sector at that point in time with 54 Category 2 and 43 Category 3 cases awaiting resource allocation, and 16 cases yet to be prioritised. There were regional hospital delays of up to 218 minutes.
2. For the 2 hours before Jade's call the Birmingham sector had been experiencing a 2 hour spike in demand. However, the real problem affecting resourcing was pandemic crews being stuck at hospitals awaiting handover . In 2023 to 2024 West Midlands Ambulance Service lost approximately 250,000 response hours due to delays at hospitals .
3. West Midlands Ambulance Service have taken a broad range of measures in recent years to tackle increasing response times including measures to reduce call demand through public education, to avert calls away from ambulance services and hospitals via clinical validation, to improve patient flow through intelligent conveying and to increase the number of resources in operation. Aside from seeking funding to recruit further paramedics and increase ambulance numbers alongside continued monitoring and learning there is nothing West Midlands Ambulance Service can identify that they can do to improve the situation further.
4. West Midlands Ambulance Service continue to fail to meet target response times and have been made the subject of a regulation 12 notice on this topic by the CQC.
5. The evidence of West Midlands Ambulance Service is that if hospital handover delays didn’t exist they would be likely to be meeting their response targets as they did before hospital delays became chronic.
In the circumstances it is my conclusion that the availability of ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life.
” 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 Make £1.6 billion available over two years to support timely hospital discharge and reduce admission delays.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. To improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans. £1.6 billion of funding was also made available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £200 million in additional funding to expand ambulance capacity and improve response times.
Verbatim wording from the response “Your report highlights that WMAS were under high demand at the time of the incident. A primary aim of the Delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £1 billion in dedicated funding to increase staffed core hospital beds by 5,000 against 2022/23 plans.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. To improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans. £1.6 billion of funding was also made available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England and the Birmingham Integrated Care Board are best placed to address local ambulance response and hospital handover delays.
Verbatim wording from the response “Your report raised concerns about ambulance response times at the West Midlands Ambulance Service (WMAS) University NHS Foundation Trust, and the hospital handover delays that they experience. You have appropriately shared your report and concerns with NHS England and Birmingham Integrated Care Board who are best placed to respond on the specific action being taken locally to improve ambulance response and handover times. You also shared your report with the Care Quality Commission who I note inspected WMAS in February 2024 and, while rating the trust good overall, raised the need to improve response times.” Source location Response from DHSC
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations