Concerns raised 2 Lack of national guidance and support for the multi-agency transition approach View source Lack of a recognised multi-agency transition pathway with clear risk, accountability and support arrangements 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
Axel Price · 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
Axel Price, who had recently turned 18, died by a ligature at some time between 15 and 23 April 2021 after discharge from hospital and Police custody into temporary accommodation. The report identified concerns about unclear agency responsibility and inadequate support during his transition from child and adolescent mental health services to adult services, including failures relating to discharge planning, risk assessment, capacity assessment and ongoing engagement.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance and support for the multi-agency transition approach
Wider context from the report “This case identified that there is a lack of clear understanding of the risk or accountability between the agencies when a young person transitions from CAMBS services at the age of 18 to adult services. The expert who provided evidence in this case said that this was a well-recognised problem and whilst services across the country had tried to address this, there was a lack of national guidance and provision .
In this particular case Axel was particularly vulnerable. He was born Yasmin Price but identified as a male from a young age. He had struggled emotionally during his teens and had indulged with alcohol and drugs. He had been detained on a number of occasions due to his mental health.
At the age of 18 he transitioned to adult services but there was a lack of a recognised pathway for him.
In the lead up to his death he had been discharged from a mental health provision following his arrest for criminal offences. He was then discharged from the hospital and subsequently the Police station to temporary accommodation.
There was little shared understanding between agencies of how Axel should best be supported and therefore he appeared to fall between the services.
Substantial changes have been made locally by Sussex Partnership Foundation NHS Trust around the transition of those from CAMBS to Adult health services but looking at other Prevention of Future Death Reports this is not just a local issue. There is a lack of national guidance and support in relation to the multi-agency approach that is needed to support those young people transitioning to adult health and social care services . Unless this is addressed nationally, sadly other deaths will occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 recognised multi-agency transition pathway with clear risk, accountability and support arrangements
Wider context from the report “This case identified that there is a lack of clear understanding of the risk or accountability between the agencies when a young person transitions from CAMBS services at the age of 18 to adult services . The expert who provided evidence in this case said that this was a well-recognised problem and whilst services across the country had tried to address this, there was a lack of national guidance and provision.
In this particular case Axel was particularly vulnerable. He was born Yasmin Price but identified as a male from a young age. He had struggled emotionally during his teens and had indulged with alcohol and drugs. He had been detained on a number of occasions due to his mental health.
At the age of 18 he transitioned to adult services but there was a lack of a recognised pathway for him .
In the lead up to his death he had been discharged from a mental health provision following his arrest for criminal offences. He was then discharged from the hospital and subsequently the Police station to temporary accommodation.
There was little shared understanding between agencies of how Axel should best be supported and therefore he appeared to fall between the services .
Substantial changes have been made locally by Sussex Partnership Foundation NHS Trust around the transition of those from CAMBS to Adult health services but looking at other Prevention of Future Death Reports this is not just a local issue. There is a lack of national guidance and support in relation to the multi-agency approach that is needed to support those young people transitioning to adult health and social care services. Unless this is addressed nationally, sadly other deaths will occur.
” Open source report
12 Apr 2024 Sabina Wood · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 3 Lack of a standardized process for creating and completing discharge summaries View source Failure to prepare discharge summaries only when patients are ready for discharge View source Failure of the discharge-summary IT system to verify completion before marking documents complete 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
Sabina Wood · 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
Sabina Wood was admitted to hospital with abdominal pain, gallstones and possible bile duct stones, underwent an ERCP, and self-discharged against medical advice. She was found unresponsive at home on 27 January 2023 and her death was recorded as a natural death, with acute haemorrhagic pancreatitis and cholelithiasis stated as the medical cause. The principal concern was that a speculative and inaccurate draft discharge summary, prepared before the ERCP and sent to her GP practice, reflected unsafe processes and could pose a risk to future patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a standardized process for creating and completing discharge summaries
Wider context from the report “I heard extensive evidence on the practice of preparing hospital discharge summaries over the two days of the inquest.
I heard that doctors commonly start to prepare discharge documentation before a patient is ready for discharge. I found that this occurred across disciplines and hospitals given that ████████ now works at the Royal Preston Hospital as a Consultant where I heard the practice also takes place. The rationale explained to me was that discharge summaries were created early and worked on throughout patient stays. This was to save time and to prevent lengthy summaries being written at the end of long stays for patients. I heard from ████████, Head of General Internal Medicine at the Blackpool Victoria Hospital that each doctor’s practice is different and it is for individual doctors to decide how they create and complete discharge summaries . I found that there is no process or procedure for discharge summaries to be created prior to discharge taking place at the Blackpool Victoria Hospital .
In this case, ████████ created the document on 20th January 2023 before Sabina underwent the ERCP procedure. This document indicated that the patient was discharged on medical advice when in fact she self-discharged against medical advice. The section on ERCP was left blank intending to be completed after the procedure took place and set out that Sabina was well in herself upon discharge with pain settling. As the discharge summary was prepared prior to the ERCP taking place it could not be known whether Sabina was well in herself or that her pain was settling.
████████ mistakenly clicked on the completed button rather than the save button on 20th January 2023. There is no mechanism for the IT system to double check the document is completed before marking the document as complete. The draft discharge summary was sent by staff on 24th January 2023 after Sabina’s self-discharge on 23rd January 2023. Staff members believed that it was ready to be sent as it was marked complete by ████████.
████████ accepted in her evidence that a draft discharge summary was sent to Sabina’s GP Practice in error and told me that her revised practice is that she instructs her junior doctors to mark the discharge summaries as drafts.
I heard evidence that Blackpool Teaching Hospital NHS Foundation Trust are undertaking a review which hasn’t yet commenced. This will look at the development of a policy of how discharge summaries are prepared. This will also include a review of the IT system with regard to creating and completing discharge summaries.
I found it very concerning to hear that speculative information in Sabrina’s case was placed on the discharge summary before her procedure took place. There is a risk that this could occur again and in the future this may be significant for a patient’s treatment and care.
I found that the sending of a draft discharge summary to Sabina’s GP Practice by Blackpool Victoria Hospital didn’t contribute to Sabina’s death. I found that a correctly completed and finalised discharge summary wouldn’t have changed the steps taken by ████████ on 25th January 2023 who was told by the patient that she was improving. It is however, of vital importance that GPs receive timely and accurate discharge summaries from hospitals which may be significant in other cases.
For that reason and not notwithstanding the review or audit that is about to commence at the Blackpool Teaching Hospital NHS Foundation Trust, I consider my duty to prevent future deaths is triggered and that there is a risk to of deaths in the future from this practice which is commonplace and neither medical specialist or hospital specific.
I found that these matters gave rise to a risk of future deaths and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 prepare discharge summaries only when patients are ready for discharge
Wider context from the report “I heard extensive evidence on the practice of preparing hospital discharge summaries over the two days of the inquest.
I heard that doctors commonly start to prepare discharge documentation before a patient is ready for discharge . I found that this occurred across disciplines and hospitals given that ████████ now works at the Royal Preston Hospital as a Consultant where I heard the practice also takes place. The rationale explained to me was that discharge summaries were created early and worked on throughout patient stays . This was to save time and to prevent lengthy summaries being written at the end of long stays for patients. I heard from ████████, Head of General Internal Medicine at the Blackpool Victoria Hospital that each doctor’s practice is different and it is for individual doctors to decide how they create and complete discharge summaries. I found that there is no process or procedure for discharge summaries to be created prior to discharge taking place at the Blackpool Victoria Hospital.
In this case, ████████ created the document on 20th January 2023 before Sabina underwent the ERCP procedure. This document indicated that the patient was discharged on medical advice when in fact she self-discharged against medical advice. The section on ERCP was left blank intending to be completed after the procedure took place and set out that Sabina was well in herself upon discharge with pain settling. As the discharge summary was prepared prior to the ERCP taking place it could not be known whether Sabina was well in herself or that her pain was settling .
████████ mistakenly clicked on the completed button rather than the save button on 20th January 2023. There is no mechanism for the IT system to double check the document is completed before marking the document as complete. The draft discharge summary was sent by staff on 24th January 2023 after Sabina’s self-discharge on 23rd January 2023. Staff members believed that it was ready to be sent as it was marked complete by ████████.
████████ accepted in her evidence that a draft discharge summary was sent to Sabina’s GP Practice in error and told me that her revised practice is that she instructs her junior doctors to mark the discharge summaries as drafts.
I heard evidence that Blackpool Teaching Hospital NHS Foundation Trust are undertaking a review which hasn’t yet commenced. This will look at the development of a policy of how discharge summaries are prepared. This will also include a review of the IT system with regard to creating and completing discharge summaries.
I found it very concerning to hear that speculative information in Sabrina’s case was placed on the discharge summary before her procedure took place. There is a risk that this could occur again and in the future this may be significant for a patient’s treatment and care.
I found that the sending of a draft discharge summary to Sabina’s GP Practice by Blackpool Victoria Hospital didn’t contribute to Sabina’s death. I found that a correctly completed and finalised discharge summary wouldn’t have changed the steps taken by ████████ on 25th January 2023 who was told by the patient that she was improving. It is however, of vital importance that GPs receive timely and accurate discharge summaries from hospitals which may be significant in other cases.
For that reason and not notwithstanding the review or audit that is about to commence at the Blackpool Teaching Hospital NHS Foundation Trust, I consider my duty to prevent future deaths is triggered and that there is a risk to of deaths in the future from this practice which is commonplace and neither medical specialist or hospital specific.
I found that these matters gave rise to a risk of future deaths and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 discharge-summary IT system to verify completion before marking documents complete
Wider context from the report “I heard extensive evidence on the practice of preparing hospital discharge summaries over the two days of the inquest.
I heard that doctors commonly start to prepare discharge documentation before a patient is ready for discharge. I found that this occurred across disciplines and hospitals given that ████████ now works at the Royal Preston Hospital as a Consultant where I heard the practice also takes place. The rationale explained to me was that discharge summaries were created early and worked on throughout patient stays. This was to save time and to prevent lengthy summaries being written at the end of long stays for patients. I heard from ████████, Head of General Internal Medicine at the Blackpool Victoria Hospital that each doctor’s practice is different and it is for individual doctors to decide how they create and complete discharge summaries. I found that there is no process or procedure for discharge summaries to be created prior to discharge taking place at the Blackpool Victoria Hospital.
In this case, ████████ created the document on 20th January 2023 before Sabina underwent the ERCP procedure. This document indicated that the patient was discharged on medical advice when in fact she self-discharged against medical advice. The section on ERCP was left blank intending to be completed after the procedure took place and set out that Sabina was well in herself upon discharge with pain settling. As the discharge summary was prepared prior to the ERCP taking place it could not be known whether Sabina was well in herself or that her pain was settling.
████████ mistakenly clicked on the completed button rather than the save button on 20th January 2023. There is no mechanism for the IT system to double check the document is completed before marking the document as complete . The draft discharge summary was sent by staff on 24th January 2023 after Sabina’s self-discharge on 23rd January 2023. Staff members believed that it was ready to be sent as it was marked complete by ████████.
████████ accepted in her evidence that a draft discharge summary was sent to Sabina’s GP Practice in error and told me that her revised practice is that she instructs her junior doctors to mark the discharge summaries as drafts.
I heard evidence that Blackpool Teaching Hospital NHS Foundation Trust are undertaking a review which hasn’t yet commenced. This will look at the development of a policy of how discharge summaries are prepared. This will also include a review of the IT system with regard to creating and completing discharge summaries.
I found it very concerning to hear that speculative information in Sabrina’s case was placed on the discharge summary before her procedure took place. There is a risk that this could occur again and in the future this may be significant for a patient’s treatment and care.
I found that the sending of a draft discharge summary to Sabina’s GP Practice by Blackpool Victoria Hospital didn’t contribute to Sabina’s death. I found that a correctly completed and finalised discharge summary wouldn’t have changed the steps taken by ████████ on 25th January 2023 who was told by the patient that she was improving. It is however, of vital importance that GPs receive timely and accurate discharge summaries from hospitals which may be significant in other cases.
For that reason and not notwithstanding the review or audit that is about to commence at the Blackpool Teaching Hospital NHS Foundation Trust, I consider my duty to prevent future deaths is triggered and that there is a risk to of deaths in the future from this practice which is commonplace and neither medical specialist or hospital specific.
I found that these matters gave rise to a risk of future deaths and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
” Open source report
10 Apr 2024 Paul Dow · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Failure to escalate calls when repeated non-response may indicate loss of consciousness View source Lack of clinician involvement during emergency calls View source Failure to assign an appropriately urgent category to calls indicating a medication overdose and suicidal intent View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Dow · 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
Paul Dow died on 3 April 2023 after taking an overdose of medication while alone in a hotel room. He had indicated that the overdose might be an attempt to take his own life, but both ambulance calls were coded as category 3, with no clinician involved at the time. There were also concerns that the lack of response to three follow-up calls, potentially indicating loss of consciousness, did not lead to escalation.
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 escalate calls when repeated non-response may indicate loss of consciousness
Wider context from the report “1. Despite giving a clear indication that he had taken an overdose of a lot of medication with an indication that he did so to take his own life the calls at 18.35 and 19.38 were both coded as category 3.
2. There was no involvement from a clinician at the time of either call.
3. Mr Dow was on his own in the hotel room. When a clinician called on 3 separate occasions there was no response. During her evidence Ms Lee, the Service Delivery Manager of the Emergency Operations Centre accepted that this could indicate that Mr Dow had lost consciousness but the call made at 18.35 was not escalated
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 clinician involvement during emergency calls
Wider context from the report “1. Despite giving a clear indication that he had taken an overdose of a lot of medication with an indication that he did so to take his own life the calls at 18.35 and 19.38 were both coded as category 3.
2. There was no involvement from a clinician at the time of either call.
3. Mr Dow was on his own in the hotel room. When a clinician called on 3 separate occasions there was no response. During her evidence Ms Lee, the Service Delivery Manager of the Emergency Operations Centre accepted that this could indicate that Mr Dow had lost consciousness but the call made at 18.35 was not escalated
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 assign an appropriately urgent category to calls indicating a medication overdose and suicidal intent
Wider context from the report “1. Despite giving a clear indication that he had taken an overdose of a lot of medication with an indication that he did so to take his own life the calls at 18.35 and 19.38 were both coded as category 3.
2. There was no involvement from a clinician at the time of either call.
3. Mr Dow was on his own in the hotel room. When a clinician called on 3 separate occasions there was no response. During her evidence Ms Lee, the Service Delivery Manager of the Emergency Operations Centre accepted that this could indicate that Mr Dow had lost consciousness but the call made at 18.35 was not escalated
” 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 NWAS is best placed to respond on the specific local action addressing the concerns.
Verbatim wording from the response “You have also shared your report with NWAS who are best placed to respond on the specific action they are taking locally to address your concerns. I am informed that NWAS has reviewed how it uses the call handling triage tool (NHS Pathways) in calls that involve patients who have taken overdoses. When NHS Pathways recognises a "risk of suicide" or "accidental poisoning or overdose" from the initial call triage, it will automatically prompt the call handler to continue with an advanced recommendation module to determine if the patient has taken an overdose of a number of higher risk medications. Patients who have taken such medicines will automatically be upgraded to a Category 2 response at the point of the call.” Source location Response from Department of Health and Social Care
Open published response
8 Apr 2024 Carole Mather · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 1 Lack of overarching guidance on applying legal frameworks to manage and protect people with chronic alcohol dependence View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Carole Mather · 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
Carole Mather, aged 66, was found dead from hypothermia in an alleyway next to her home on 2 January 2023. She had attended hospital the previous day while intoxicated and complaining of shortness of breath, but discharged herself against medical advice. The principal concerns included the complexity of assessing mental capacity in people with chronic alcohol dependence and the lack of overarching guidance for health and social care practitioners on applying legal frameworks to manage and protect them.
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 overarching guidance on applying legal frameworks to manage and protect people with chronic alcohol dependence
Wider context from the report “It was against this background that the Court heard of the lack of overarching guidance for health and social care practitioners which specifically addresses the application of legal frameworks available to manage and protect those with a chronic dependence on alcohol . Such guidance would be of benefit to health and social care practitioners and by extension to the individuals affected.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing Mental Capacity Act safeguards, including DoLS and practitioners’ case-law duties, are relied on to protect patients lacking capacity.
Verbatim wording from the response “If a patient was found to not have the mental capacity to discharge themselves, and they are or will be deprived of their liberty, then the hospital may need to consider whether to use the Deprivation of Liberty Safeguards (DoLS), under the Mental Capacity Act 2005. The DoLS can authorise the deprivation of liberty of a person being accommodated in a hospital or care home for the purpose of providing care or treatment. Any such restrictions placed on a person in these circumstances must be in their best interests and necessary and proportionate. Decision makers should therefore make full consideration as to whether less restrictive options, such as appropriate support packages, can be implemented in place of DoLS authorisation.” Source location Response from Department of Health and Social Care
Open published response
5 Apr 2024 Tracey Ann FARNDON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Failure to recognise the seriousness of a low or unrecordable blood pressure and continue observations View source Failure to make further attempts to assess an unrecordable blood pressure View source Insufficient emergency department staffing to care for, monitor and manage patients View source Failure to recognise and consider sepsis despite its variable signs and symptoms 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
Tracey Ann FARNDON · 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
Tracey Ann FARNDON was admitted to hospital with diarrhoea, vomiting and severe lower back pain, deteriorated rapidly, suffered cardiac arrest and could not be saved. The post-mortem identified severe pneumonia and a septic spleen, with the medical cause of death recorded as septic shock due to sepsis secondary to community-acquired pneumonia. Concerns included delays in recognising and treating sepsis, failure to respond appropriately to an unrecordable low blood pressure, and emergency department overcrowding and insufficient staffing.
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 recognise the seriousness of a low or unrecordable blood pressure and continue observations
Wider context from the report “3. Ms Farndon's BP was not recordable when she first presented at the emergency department. It was likely to be very low. This was not considered by the staff concerned and no further attempts were made to assess Ms Farndon's BP. There is a concern staff do not understand the implication of a low BP , the importance of continued observations when a key parameter cannot be recorded and that this may indicate the patient is seriously unwell . This raises a concern of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to make further attempts to assess an unrecordable blood pressure
Wider context from the report “3. Ms Farndon's BP was not recordable when she first presented at the emergency department. It was likely to be very low. This was not considered by the staff concerned and no further attempts were made to assess Ms Farndon's BP . There is a concern staff do not understand the implication of a low BP, the importance of continued observations when a key parameter cannot be recorded and that this may indicate the patient is seriously unwell. This raises a concern of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient emergency department staffing to care for, monitor and manage patients
Wider context from the report “1. The inquest heard how the emergency department was, and continues to be, overwhelmed with patients with insufficient staff to care for, monitor and manage those patients . There is continued regular use of agency staff . This directly impacts patients' safety and is a risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and consider sepsis despite its variable signs and symptoms
Wider context from the report “2. The inquest heard how staff failed to consider a diagnosis of sepsis throughout Ms Farndon's admission . There is a concern staff do not fully understand the variable signs and symptoms of sepsis and there is a risk of 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 Make £1.6 billion available over two years to support timely hospital discharge and reduce emergency department overcrowding.
Verbatim wording from the response “A key part of the plan has been to increase hospital capacity to reduce overcrowding in A&E. We have delivered 5,000 more staffed, permanent beds this year compared to 2022-23. A whole-system approach is needed to ensure people get the emergency care they need. This is why £1.6 billion of funding has been 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 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 Publish the delivery plan for recovering urgent and emergency care services.
Verbatim wording from the response “Your report raised concerns about the demand and capacity in Queen Elizabeth Hospital’s Emergency Department. I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’, which aims to deliver sustained improvements in waiting times. Our ambitions include improving the Accident and Emergency (A&E) Department waiting times and reduce overcrowding, so that, by March 2025, 78% of patients are admitted, transferred, or discharged from A&E within four hours. A&E waiting times have improved this year following the delivery plan’s publication, with national A&E 4-hour performance improving from 71.5% in March 2023 to 74.2% in 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 Deliver 5,000 additional staffed, permanent hospital beds to increase emergency care capacity.
Verbatim wording from the response “A key part of the plan has been to increase hospital capacity to reduce overcrowding in A&E. We have delivered 5,000 more staffed, permanent beds this year compared to 2022-23. A whole-system approach is needed to ensure people get the emergency care they need. This is why £1.6 billion of funding has been 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 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 Continue working with NHS England to identify resources needed for healthcare professionals to recognise and respond appropriately to patient deterioration.
Verbatim wording from the response “that updates to national sepsis guidance are disseminated and well recognised amongst a wide range of healthcare professionals who may encounter sepsis and acute deterioration. NHS England has developed several sepsis training and education resources, including e-learning, sector specific toolkits, and the ‘sepsis educational digital game,’ an accessible introduction to sepsis for clinical and non-clinical staff. We will continue to work with NHS England to understand what resources are needed to ensure that healthcare professionals recognise and respond appropriately when patients deteriorate.” 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 Trust is responsible for responding directly to concerns about assessing the patient’s low blood pressure.
Verbatim wording from the response “Your report also raised concerns regarding the assessment of Ms Farndon’s low blood pressure. I note you have shared your report and concerns with University Hospitals Birmingham NHS Foundation Trust, to respond directly to your matters of concern. I have included below some of the local actions that the Trust has committed to in response to the concerns in your report.” Source location Response from Department of Health and Social Care
Open published response
2 Apr 2024 Alan Andrew SOANE · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure to take national action to address the Consultant Histopathologist shortage View source Failure to provide a Consultant Histopathologist at Hepato-pancreato-biliary MDT meetings View source National shortage of Consultant Histopathologists View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alan Andrew SOANE · 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
Alan Andrew Soane underwent a Whipple’s procedure after an incorrect diagnosis of duodenal cancer and died on 26 June 2023 from known complications of the procedure. The report raises concerns about the absence of a Consultant Histopathologist at Hepato-pancreato-biliary MDT meetings and the wider national shortage of Consultant Histopathologists, which was acknowledged as contributing to the incorrect diagnosis.
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 take national action to address the Consultant Histopathologist shortage
Wider context from the report “The NHS Trust in this case was, and remains, unable to provide for the presence of a Consultant Histopathologist at Hepato-pancreato-biliary MDT meetings. It was acknowledged that this was a factor that led to Mr Soane being given a cancer diagnosis that was incorrect. This inability to provide a Consultant Histopathologist is something that has been on the Trust’s risk register for over five years and recruitment exercises have taken place, to no avail. I was told in evidence that this is attributed to the fact that nationally, 25% of Consultant Histopathologist roles remain vacant; in short, there is a national shortage of Consultant Histopathologists.
The concern here is that a national shortage of Consultant Histopathologists puts a widespread proportion of the patient population at a significant risk.
I was reassured that the individual NHS Trust had made continued efforts to reduce the risks they identified, by attempting to recruit to the vacant post. However, I was not reassured that action has been taken at a national level to address the shortage generally .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a Consultant Histopathologist at Hepato-pancreato-biliary MDT meetings
Wider context from the report “The NHS Trust in this case was, and remains, unable to provide for the presence of a Consultant Histopathologist at Hepato-pancreato-biliary MDT meetings . It was acknowledged that this was a factor that led to Mr Soane being given a cancer diagnosis that was incorrect. This inability to provide a Consultant Histopathologist is something that has been on the Trust’s risk register for over five years and recruitment exercises have taken place, to no avail. I was told in evidence that this is attributed to the fact that nationally, 25% of Consultant Histopathologist roles remain vacant; in short, there is a national shortage of Consultant Histopathologists.
The concern here is that a national shortage of Consultant Histopathologists puts a widespread proportion of the patient population at a significant risk.
I was reassured that the individual NHS Trust had made continued efforts to reduce the risks they identified, by attempting to recruit to the vacant post. However, I was not reassured that action has been taken at a national level to address the shortage generally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation National shortage of Consultant Histopathologists
Wider context from the report “The NHS Trust in this case was, and remains, unable to provide for the presence of a Consultant Histopathologist at Hepato-pancreato-biliary MDT meetings. It was acknowledged that this was a factor that led to Mr Soane being given a cancer diagnosis that was incorrect. This inability to provide a Consultant Histopathologist is something that has been on the Trust’s risk register for over five years and recruitment exercises have taken place, to no avail. I was told in evidence that this is attributed to the fact that nationally, 25% of Consultant Histopathologist roles remain vacant; in short, there is a national shortage of Consultant Histopathologists .
The concern here is that a national shortage of Consultant Histopathologists puts a widespread proportion of the patient population at a significant risk .
I was reassured that the individual NHS Trust had made continued efforts to reduce the risks they identified, by attempting to recruit to the vacant post. However, I was not reassured that action has been taken at a national level to address the shortage generally.
” 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 Continue working with NHS England and system partners to deliver the Long Term Workforce Plan’s workforce ambitions for patient safety and outcomes.
Verbatim wording from the response “The NHS Long Term Workforce Plan (LTWP), published by NHS England in June 2023, 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. The plan outlines the action needed to ensure we train and retain more staff, and reform medical education and training to put the NHS workforce on a sustainable footing for the future.” 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 Increase domestic medical school places in England to expand the future pool of histopathologists and other specialists.
Verbatim wording from the response “The LTWP sets out the aim to double the number of medical school places in England to 15,000 places a year by 2031/32, and to work towards this expansion by increasing places by a third, to 10,000 a year, by 2028/29. We have brought forward the trajectory of this planned expansion for the last 2 years, having allocated 205 and 350 additional places for the 2024/25 and 2025/26 academic years respectively. There are now an additional 1,500 medical school places per year for domestic students in England – a 25% increase, taking the total number of medical school places in England to 7,500 each year. These expansions will increase the pool from which future histopathologists and other specialists can be drawn.” 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 should further address concerns about consultant histopathologist attendance at meetings and national vacancies.
Verbatim wording from the response “In preparing this response, Departmental officials have made enquiries with NHS England (NHSE). I have been informed that NHSE has been granted an extension to 18 June to send a response to you. As an Executive Agency of the Department of Health and Social Care, NHSE’s response should further address the concern you raised.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 4 Systemic failure causing ambulance delays View source Failure to transfer patients from emergency departments to hospital wards when clinically indicated View source Delays in ambulance-to-hospital patient handover View source Insufficient domiciliary or residential care capacity for hospital discharge View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
PATRICIA ANNE VAN DER EYKEN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Patricia Anne Van Der Eyken, aged 93, called 999 with chest pain radiating down her left arm on 13 September 2023 and was found deceased when an ambulance arrived two hours and 37 minutes later. The principal concern was a systemic ambulance delay linked to healthcare and social care capacity and handover failures, which the court found likely contributed to her death by preventing lifesaving 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 Systemic failure causing ambulance delays
Wider context from the report “1. Patricia’s death followed an ambulance delay, attributable to a systemic failure , which is likely to have contributed to Patricia’s death by preventing lifesaving treatment.
2. The systemic failure was found to be due to issues within healthcare services external to SWAST and notwithstanding increases in SWAST staff numbers and ambulance numbers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer patients from emergency departments to hospital wards when clinically indicated
Wider context from the report “8. It was found that the build-up of patients in wards (patients who are medically fit for discharge) means that the hospitals are, at times, unable to transfer patients from the emergency department to hospital wards when clinically indicated . This in turn leads to a build up of patients in emergency departments. This leads to handover delays between ambulance and hospital, namely ambulance crews being unable to transfer patients from ambulances into the emergency department. It was found that there is a strong correlation between ambulance handover delays and increasing ambulance response times. The report stated:
“It is as simple as the longer a patient is waiting in an ambulance outside a hospital, the longer the next patient will wait for an ambulance”.
9. The investigation report states
‘…SWAST is experiencing by far the highest levels of handover delays seen in the Trust’s history. Handover delays result in multiple ambulance resources being held at hospitals for extended periods, thereby limiting the number of resources on the road to respond to waiting incidents. With fewer resources on the road, the response times to patients inevitably increases…
….The impact of the delays …is devastating, most significant, and most immediately evident to patients and their families and carers. Less evident is the secondary, detrimental effect these delays can bring to the service as a whole. This investigation found that delays are having an additional profound impact on staff morale and their mental wellbeing.”
10. The court considered SWAST performance data for 2023 in connection with handover delays between ambulances and hospitals. There is a target for crews to handover the care of their patients within 15 minutes of arriving at an Emergency Department. Anything above this constitutes a delay which impacts on the availability of resources. The data revealed that in September 2023, handover delays (in excess of 15 minutes), cost the ambulance service 2,981 hours at Treliske. This is equivalent to 271 ambulance crew shifts. At Derriford in the same month, handover delays (in excess of 15 minutes) cost the ambulance service 6,359 hours, which is equivalent to 581 ambulance crew shifts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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-to-hospital patient handover
Wider context from the report “8. It was found that the build-up of patients in wards (patients who are medically fit for discharge) means that the hospitals are, at times, unable to transfer patients from the emergency department to hospital wards when clinically indicated. This in turn leads to a build up of patients in emergency departments. This leads to handover delays between ambulance and hospital, namely ambulance crews being unable to transfer patients from ambulances into the emergency department. It was found that there is a strong correlation between ambulance handover delays and increasing ambulance response times. The report stated:
“It is as simple as the longer a patient is waiting in an ambulance outside a hospital, the longer the next patient will wait for an ambulance”.
9. The investigation report states
‘…SWAST is experiencing by far the highest levels of handover delays seen in the Trust’s history. Handover delays result in multiple ambulance resources being held at hospitals for extended periods, thereby limiting the number of resources on the road to respond to waiting incidents . With fewer resources on the road, the response times to patients inevitably increases…
….The impact of the delays …is devastating, most significant, and most immediately evident to patients and their families and carers. Less evident is the secondary, detrimental effect these delays can bring to the service as a whole. This investigation found that delays are having an additional profound impact on staff morale and their mental wellbeing.”
10. The court considered SWAST performance data for 2023 in connection with handover delays between ambulances and hospitals. There is a target for crews to handover the care of their patients within 15 minutes of arriving at an Emergency Department. Anything above this constitutes a delay which impacts on the availability of resources. The data revealed that in September 2023, handover delays (in excess of 15 minutes), cost the ambulance service 2,981 hours at Treliske. This is equivalent to 271 ambulance crew shifts. At Derriford in the same month, handover delays (in excess of 15 minutes) cost the ambulance service 6,359 hours, which is equivalent to 581 ambulance crew shifts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 domiciliary or residential care capacity for hospital discharge
Wider context from the report “5. The court considered the findings in the SWAST Patient Safety Incident Investigation Report & an associated investigation conducted by the Healthcare Services Safety Investigation Branch (HSSIB). These investigations found that…
‘…there is a direct link between patients waiting in the hospital for discharge to social care, and patients being cared for inside ambulances and Emergency Departments.’
6. In other words, the investigations found that there is a direct link between failings in social care provision and ambulance delays. The failings in social care provision were found to have a knock-on effect through healthcare services. It was found that at times hospitals were unable to transfer patients from hospital wards into the community when clinically indicated. This is because of the difficulty in securing sufficient domiciliary or residential care, as and when required . This leads to delayed discharges from hospital of patients deemed medically fit for discharge.
7. Furthermore, it was found that delayed discharge can lead to an increase in rehabilitation and care needs. This is an effect of delayed discharge leading to further impact upon hospital capacity.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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 Provide £200 million to ambulance trusts to expand capacity and improve ambulance response times.
Verbatim wording from the response “Your report highlights that SWAST and local hospitals were experiencing high demand and long handover delays. 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 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 SWAST and local hospitals were experiencing high demand and long handover delays. 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 Launch a £40 million fund for local authorities facing urgent and emergency care challenges.
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 position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specific actions to reduce handover delays and improve ambulance response times are best undertaken locally by SWAST and Royal Cornwall Hospital.
Verbatim wording from the response “Your report raised concerns about ambulance response times by South Western Ambulance Service NHS Foundation Trust (SWAST) in particular how this impacted by handover delays and issues with discharging patients from hospital.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 4 Failure to transfer emergency department patients to hospital wards when clinically indicated View source Crowding and extremely long waiting times in the emergency department View source Failure to complete ambulance handovers within 15 minutes of arrival at the emergency department View source Failure to secure sufficient domiciliary or residential care for medically fit hospital patients 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
ROBERT ANDREW PROWSE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Robert Andrew Prowse, who was 86, became unconscious and was suspected of having had a seizure before an ambulance was called. The ambulance arrived after a delay of three hours and 47 minutes, and further delays occurred in transferring him into the emergency department, where sepsis was identified; he died before prescribed antibiotics could be administered. The report identified systemic ambulance and hospital delays, including emergency department crowding and delayed patient handovers, as concerns that likely contributed to preventing lifesaving 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 transfer emergency department patients to hospital wards when clinically indicated
Wider context from the report “6. In other words, the investigations found that there is a direct link between failings in social care provision and ambulance delays. The failings in social care provision were found to have a knock-on effect through healthcare services. It was found that at times hospitals were unable to transfer patients from hospital wards into the community when clinically indicated. This is because of the difficulty in securing sufficient domiciliary or residential care, as and when required. This leads to delayed discharges from hospital of patients deemed medically fit for discharge.
7. Furthermore, it was found that delayed discharge can lead to an increase in rehabilitation and care needs. This is an effect of delayed discharge leading to further impact upon hospital capacity.
8. It was found that the build-up of patients in wards (patients who are medically fit for discharge) means that the hospitals are, at times, unable to transfer patients from the emergency department to hospital wards when clinically indicated . This in turn leads to a build up of patients in 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 Crowding and extremely long waiting times in the emergency department
Wider context from the report “9. The court heard evidence that Treliske have established a triage centre in the car park, known as the Rapid Assessment and Treatment Centre. The primary purpose of triage is to identify those patients in immediately life-threatening condition. The triage centre is an attempt to mitigate the risks due to ambulance delay and overcrowding in ED. ████████ stated that the vast majority of patients are now seen in the car park, inside ambulances or in the triage centre, rather than in ED.
10. The court heard evidence of crowding at Treliske ED with patients being accommodated in the corridors . Evidence was heard from ████████ regarding a scientific study by Royal College of Emergency Medicine (published in the Emergency Medicine Journal). This study discussed the adverse impact of crowding in ED . The study calculated the estimated number of excess deaths occurring across the United Kingdom associated with crowding and extremely long waiting times . The study showed that for every 72 patients waiting between eight-
and 12-hours from their time of arrival in the Emergency Department there is one patient death.
11. The court heard evidence that in September 2023 patients had spent a total of 14,327 hours in Treliske ED when it was clinically appropriate for these patients to be discharged or moved to a ward . This period of time is equivalent to closing 19 cubicles in Treliske ED for a whole month. Treliske ED has 26 cubicles.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to complete ambulance handovers within 15 minutes of arrival at the emergency department
Wider context from the report “12. The build-up of patients in the emergency department leads to handover delays between ambulance and hospital, namely ambulance crews being unable to transfer patients from ambulances into the emergency department . It was found that there is a strong correlation between ambulance handover delays and increasing ambulance response times. The investigation report stated:
‘It is as simple as the longer a patient is waiting in an ambulance outside a hospital, the longer the next patient will wait for an ambulance’.
13. The investigation report states
‘…SWAST is experiencing by far the highest levels of handover delays seen in the Trust’s history. Handover delays result in multiple ambulance resources being held at hospitals for extended periods, thereby limiting the number of resources on the road to respond to waiting incidents . With fewer resources on the road, the response times to patients inevitably increases…
….The impact of the delays …is devastating, most significant, and most immediately evident to patients and their families and carers. Less evident is the secondary, detrimental effect these delays can bring to the service as a whole. This investigation found that delays are having an additional profound impact on staff morale and their mental wellbeing.’
14. The court considered SWAST performance data for 2023 in connection with handover delays between ambulances and hospitals. There is a target for crews to handover the care of their patients within 15 minutes of arriving at an Emergency Department. Anything above this constitutes a delay which impacts on the availability of resources. The data revealed that in September 2023, handover delays (in excess of 15 minutes), cost the ambulance service 2,981 hours at Treliske. This is equivalent to 271 ambulance crew shifts. At Derriford in the same month, handover delays (in excess of 15 minutes) cost the ambulance service 6,359 hours, which is equivalent to 581 ambulance crew shifts.
15. The court considered data for 2023 showing total operational resource hours lost to handover delays in excess of 15 minutes. The total lost by SWAST at Treliske was 35,583 hours. At Derriford the total lost in 2023 was 53,080 hours.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to secure sufficient domiciliary or residential care for medically fit hospital patients
Wider context from the report “6. In other words, the investigations found that there is a direct link between failings in social care provision and ambulance delays. The failings in social care provision were found to have a knock-on effect through healthcare services. It was found that at times hospitals were unable to transfer patients from hospital wards into the community when clinically indicated . This is because of the difficulty in securing sufficient domiciliary or residential care, as and when required . This leads to delayed discharges from hospital of patients deemed medically fit for discharge .
7. Furthermore, it was found that delayed discharge can lead to an increase in rehabilitation and care needs. This is an effect of delayed discharge leading to further impact upon hospital capacity.
8. It was found that the build-up of patients in wards (patients who are medically fit for discharge) means that the hospitals are, at times, unable to transfer patients from the emergency department to hospital wards when clinically indicated. This in turn leads to a build up of patients in 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 Continue working with NHS England to reduce patient waiting times.
Verbatim wording from the response “However, I recognise there is still more to do to reduce patient waiting times further, and the Government will continue to work with NHS England to achieve this.” 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 Maintain the uplift of 5,000 staffed, permanent hospital beds delivered through the urgent and emergency care plan.
Verbatim wording from the response “Your report also highlights that Royal Cornwall Hospital was experiencing high demand with long handover delays. I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals, as you rightly identify in your report, can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022/23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. We have also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 12,000 beds available nationally.” 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 Publish and implement the delivery plan for recovering urgent and emergency care services.
Verbatim wording from the response “I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times. Our ambition for this year is to reduce Category 2 ambulance response times to 30 minutes on average. The plan is available at https://www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf” 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 Ensure every acute hospital has access to a care transfer hub supporting complex discharges and early planning.
Verbatim wording from the response “We are also investing an additional £1 billion this year through the Discharge Fund, to support the NHS and local authorities to ensure timely and effective discharge from hospital. This funding follows £600 million last year and £500 million in 2022/23. The NHS and local authorities are using this funding to help provide people with the right care in the right place when they are discharged from hospital. We have also ensured every acute hospital has access to a care transfer hub, bringing together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support with a view to promoting early planning and timely discharge. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads.” 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 an additional £1 billion through the Discharge Fund to support timely and effective hospital discharge.
Verbatim wording from the response “We are also investing an additional £1 billion this year through the Discharge Fund, to support the NHS and local authorities to ensure timely and effective discharge from hospital. This funding follows £600 million last year and £500 million in 2022/23. The NHS and local authorities are using this funding to help provide people with the right care in the right place when they are discharged from hospital. We have also ensured every acute hospital has access to a care transfer hub, bringing together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support with a view to promoting early planning and timely discharge. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads.” 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 and RCHT are best placed to determine and implement local action to reduce handover delays and improve ambulance response times.
Verbatim wording from the response “You have appropriately shared your report and concerns with SWAST and Royal Cornwall Hospital Trust (RCHT), who are best placed to respond on the specific action they are taking locally to reduce handover delays and improve ambulance response times.” Source location Response from Department of Health and Social Care
Open published response
25 Mar 2024 Christopher Edward SIDLE · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 8 Failure to fully and properly record the rationale for decisions View source Insufficient telephone-based support to recognise ongoing concerns View source Shortage of inpatient mental health beds View source Failure to circulate important emails to relevant CRHTT personnel View source Delays in arranging assessments for people requiring an immediate response View source Lack of understanding of mental capacity assessment View source Failure to conduct full and proper assessments and independently verify service users’ responses View source Lack of understanding of the scope and limitations of community team services 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
Christopher Edward SIDLE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Sidle had schizophrenia and experienced a deterioration in his mental health during June 2023. After several assessments by mental health services, he was not admitted to hospital; on 1 July 2023 he jumped from a moving taxi, suffered life-threatening head injuries and died on 4 July 2023 after life-sustaining therapies ceased. The report identified inadequate assessments and missed opportunities to provide appropriate and timely care, alongside concerns about crisis-team training, communication, risk assessment, community support, and the shortage of inpatient mental health beds.
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 fully and properly record the rationale for decisions
Wider context from the report “3. There remains a lack of understanding with regard to assessing a person’s mental capacity to make decisions and to fully and properly record the rationale for making decisions .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient telephone-based support to recognise ongoing concerns
Wider context from the report “4. Support provided by FACT is usually carried out by telephone and will in some circumstances not be sufficient to recognise ongoing concerns , for instance with regard to medication concordance .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Shortage of inpatient mental health beds
Wider context from the report “7. Evidence was heard of a nationwide shortage of inpatient mental health beds . Action has been taken by NSFT in an effort to minimise impact, but this does remain an ongoing 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 circulate important emails to relevant CRHTT personnel
Wider context from the report “5. Important emails were not circulated to relevant personnel within the CRHTT . The evidence remains unclear what happened to the emails and why they did not reach the appropriate member of the team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in arranging assessments for people requiring an immediate response
Wider context from the report “6. A person can be identified at triage risk assessment as being in need of an “immediate response, within 4 hours” but an assessment is then arranged for within a 24-hour period .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 mental capacity assessment
Wider context from the report “3. There remains a lack of understanding with regard to assessing a person’s mental capacity to make decisions and to fully and properly record the rationale for making decisions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct full and proper assessments and independently verify service users’ responses
Wider context from the report “1. Despite additional face to face training being made available to the CRHTT, witness evidence was heard which does not reflect the findings of the investigation and does not recognise the need for a full and proper assessment and the need not to accept a service user’s response to questions 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 Lack of understanding of the scope and limitations of community team services
Wider context from the report “2. There remains a lack of understanding amongst the CRHTT with regard to the scope and limitations of other services available within the community team .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fund the national rollout of specialised mental health ambulances supported by practitioners trained in co-occurring physical and mental health needs.
Verbatim wording from the response “For those in crisis, we are providing £150 million of capital investment for mental health urgent and emergency care infrastructure over 2023/24 and 2024/25. This includes investment into a range of wider local mental health infrastructure schemes, including new and improved crisis cafes, crisis houses, health-based places of safety and improvements to emergency departments and crisis lines. Over 160 schemes have been allocated funding by NHS England so far and 99 have been completed. The funding will also provide for specialised mental health ambulances which will be rolled out across the country – and be supported by practitioners trained to provide advice and treatments in cases of co-occurring physical and mental health issues.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and publish statutory guidance for discharge from mental health inpatient settings.
Verbatim wording from the response “Timely discharge of patients who are ready to be discharged is important to free up beds for those who need them. To support adult social care and discharges across the NHS, including from mental health inpatient settings, up to £2.8 billion was made available in 2023/24 and £4.7 billion in 2024/25, reducing bed occupancy. The Department has also worked with NHS England and other system partners to develop statutory guidance for discharge from all mental health inpatient settings, which was published in January 2024. This sets out how NHS bodies and local authorities can work together to support the discharge process, improving flow and ensuring the right support in the community. The guidance is available at: Hospital discharge and community support guidance - GOV.UK (www.gov.uk)” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest almost £1 billion in expanded adult community mental health services by March 2024.
Verbatim wording from the response “Through the NHS Long Term Plan, we have invested almost £1 billion extra in community mental health care for adults by March 2024, compared to 2018/19, expanding and transforming community mental health services. The long-term aim set out within the NHS Long-Term Plan is to improve community support for those with serious mental illness to avoid the need for an inpatient admission where possible. As part of this, major expansion in funding for community mental health services commenced in all areas in 2021/22 which also aim to reduce pressure on beds. However, we recognise that there are occasions where a mental health bed is not available locally. The 2024/25 NHS priorities and operations planning guidance has a commitment to improving patient flow and working towards eliminating inappropriate out of area placements.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve patient flow and work towards eliminating inappropriate out-of-area mental health placements.
Verbatim wording from the response “Through the NHS Long Term Plan, we have invested almost £1 billion extra in community mental health care for adults by March 2024, compared to 2018/19, expanding and transforming community mental health services. The long-term aim set out within the NHS Long-Term Plan is to improve community support for those with serious mental illness to avoid the need for an inpatient admission where possible. As part of this, major expansion in funding for community mental health services commenced in all areas in 2021/22 which also aim to reduce pressure on beds. However, we recognise that there are occasions where a mental health bed is not available locally. The 2024/25 NHS priorities and operations planning guidance has a commitment to improving patient flow and working towards eliminating inappropriate out of area placements.” 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 capital investment for urgent and emergency mental health infrastructure, including crisis services, emergency departments and crisis lines.
Verbatim wording from the response “For those in crisis, we are providing £150 million of capital investment for mental health urgent and emergency care infrastructure over 2023/24 and 2024/25. This includes investment into a range of wider local mental health infrastructure schemes, including new and improved crisis cafes, crisis houses, health-based places of safety and improvements to emergency departments and crisis lines. Over 160 schemes have been allocated funding by NHS England so far and 99 have been completed. The funding will also provide for specialised mental health ambulances which will be rolled out across the country – and be supported by practitioners trained to provide advice and treatments in cases of co-occurring physical and mental health issues.” 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 Make funding available to support adult social care and NHS discharges, including from mental health inpatient settings.
Verbatim wording from the response “Timely discharge of patients who are ready to be discharged is important to free up beds for those who need them. To support adult social care and discharges across the NHS, including from mental health inpatient settings, up to £2.8 billion was made available in 2023/24 and £4.7 billion in 2024/25, reducing bed occupancy. The Department has also worked with NHS England and other system partners to develop statutory guidance for discharge from all mental health inpatient settings, which was published in January 2024. This sets out how NHS bodies and local authorities can work together to support the discharge process, improving flow and ensuring the right support in the community. The guidance is available at: Hospital discharge and community support guidance - GOV.UK (www.gov.uk)” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 2 Delays in offloading patients at hospitals tying up ambulance resources View source Failure to provide Category 2 ambulance responses within 40 minutes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jean WALKER · 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
Jean WALKER became unwell at home on 4 November 2022 and was struggling to breathe when her daughter called 999 at 0348. She died before the ambulance arrived at 0542 and was pronounced dead at 0551. The principal concerns were the delayed ambulance response and hospital offloading delays that reduced available ambulance resources; the inquest concluded that the delay resulted in a missed opportunity to provide medical assistance, although it could not be said that earlier intervention would have prevented her 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 Delays in offloading patients at hospitals tying up ambulance resources
Wider context from the report “(2) There was a significant delay in offloading patients at hospitals which tied up ambulance resource 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 Category 2 ambulance responses within 40 minutes
Wider context from the report “(1) The ambulance service was called at 0348 on 4 November 2022 and the call was coded as a Category 2 call requiring a response within 40 minutes . The ambulance finally arrived at 0542 on 4 November 2022, 1 hour and 56 minutes after the call .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional funding to expand ambulance capacity and increase staffed hospital beds.
Verbatim wording from the response “Your report highlights reduced ambulance resource in the Yorkshire region 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
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation West Yorkshire Integrated Care Board will respond on the specific local actions being taken to support ambulance response times.
Verbatim wording from the response “Your report raised concerns about ambulance response times and capacity at Yorkshire Ambulance Service NHS Trust (YAS) as a result of handover delays at hospitals. These concerns were also raised directly with the responsible NHS Integrated Care Board.” Source location Response from DHSC
Open published response
14 Mar 2024 Joseph Michael Miller · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Failure to ensure consistent ambulance call categorisation pathways across England View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Joseph Michael Miller · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 31 May 2023, Joseph Michael Miller suffered seizures at home, became unconscious, and did not regain consciousness despite resuscitation attempts. He was declared dead on 5 June 2023 after tests confirmed severe hypoxic brain injury. The report raised concerns that differing ambulance service pathways can lead to inconsistent call categorisation and affect the dispatch of potentially lifesaving attendance.
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 consistent ambulance call categorisation pathways across England
Wider context from the report “1. The inquest heard evidence that different ambulance services use different pathways that can impact how calls are categorised /downgraded . The consequence of this is that how the ambulance services across England deal with a call varies depending on where you live . As an example in this inquest, because of where Joseph lived, calls can go to EMAS or NWAS depending on which mobile telephone mast the call pings on. The initial call went to EMAS who on being told he was no longer fitting downgraded the call, in line with their pathway. The inquest was told that had the call been dealt with by NWAS they would not have downgraded the call to a category 3 in this situation because that was not how their pathway operated.
2. The consequence of these different pathways is that there is not a consistent approach to call categorisation across the country which can have a significant impact on the dispatch of potentially lifesaving attendance by the ambulance service .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing mapping and continual review of triage categorisation are considered sufficient to reduce unwarranted variation and support appropriate ambulance prioritisation.
Verbatim wording from the response “In considering the concerns raised about the potential for variation between categorisation, NHSE has advised the Department that it has in place a process to appropriately map the outcomes of 999 call triage systems against ambulance response time categories. NHSE has responsibility for the production, maintenance, review and revision of the dataset used in these systems, which is managed by the NHSE-chaired Emergency Call Prioritisation Advisory Group (ECPAG). ECPAG keeps the categorisation of calls under continual review, and ambulance services support this process through providing evidence and expertise to reduce unwarranted variation across services, helping ensure appropriate prioritisation, equity of access and uniformity of response across England.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for overseeing ambulance services and maintaining, reviewing and revising the triage dataset through ECPAG.
Verbatim wording from the response “Your report raised concerns about the two call triage systems in use by NHS ambulance trusts, and the potential for patients to be given a different ambulance categorisation depending on the system used. The Department’s officials have shared your report with the East Midlands Ambulance Service (EMAS), North West Ambulance Service (NWAS) and NHS England (NHSE) as the body responsible for oversight of NHS ambulance services.” Source location Response from Department of Health and Social Care
Open published response
14 Mar 2024 Tobias Ryse Mannering-Jones · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Lack of resources for stable housing solutions for vulnerable young people View source Lack of overall ownership for coordinated multi-agency support View source Lack of resources for sustained support of vulnerable young people experiencing homelessness View source Delays in access to mental health support View source Failure of public service contact arrangements for people without a stable address View source Failure to recognise sexual exploitation and vulnerability among homeless LGBTQIA young people View source Failure to use regular MDTs to share and understand multi-agency information View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Tobias Ryse Mannering-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
Tobias Mannering-Jones became homeless, isolated and vulnerable, experienced mental health difficulties, drug use and sexual exploitation, and was found dead at Portland Basin Marina on 21 February 2023. The inquest identified concerns about delays in mental health support, inadequate housing and sustained support for vulnerable homeless young people, difficulties contacting people without telephones or addresses, failure to recognise exploitation, and the need for coordinated agency responsibility.
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 resources for stable housing solutions for vulnerable young people
Wider context from the report “2. The inquest also heard evidence of the impact of homelessness and consequential vulnerability on a young person like Tobias and that the demands on Local Authorities meant that even where vulnerability was recognised there were not resources for either sustained support and stable housing solutions . The evidence was that as a consequence young vulnerable people had to rely on homeless shelters where they were exposed to additional negative influences and as in Tobias’s case abuse due to their sexuality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 overall ownership for coordinated multi-agency support
Wider context from the report “5. The evidence before the inquest was that where multiple agencies were involved it was fundamental that one agency/person took overall ownership/responsibility to ensure a coordinated and effective approach using regular MDTs to understand the information that all agencies had in their possession and to offer effective support.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of resources for sustained support of vulnerable young people experiencing homelessness
Wider context from the report “2. The inquest also heard evidence of the impact of homelessness and consequential vulnerability on a young person like Tobias and that the demands on Local Authorities meant that even where vulnerability was recognised there were not resources for either sustained support and stable housing solutions. The evidence was that as a consequence young vulnerable people had to rely on homeless shelters where they were exposed to additional negative influences and as in Tobias’s case abuse due to their sexuality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 access to mental health support
Wider context from the report “1. The inquest was told that Tobias had sought and had been referred for mental health support however due to the high demand and long waiting lists he was still on a waiting list at the time of his death . The evidence before the inquest was that long delays were still an issue and were not restricted to Tameside but were part of a national picture of delays and long waiting lists for those seeking help with 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 Failure of public service contact arrangements for people without a stable address
Wider context from the report “3. Evidence was also heard that a person who has to rely on a homeless shelter can then become uncontactable to public service providers as they have no address for contact which means they then have even less chance of accessing support .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise sexual exploitation and vulnerability among homeless LGBTQIA young people
Wider context from the report “4. The inquest was told that young adults who are homeless are often sexually exploited and that those who identify as LGBTQIA can be particularly vulnerable and that the underlying vulnerability and risk was not always appreciated by those dealing with young homeless people and that it could be mistaken by agencies as a lifestyle choice rather than what it actually was, i.e., exploitation by an older adult .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to use regular MDTs to share and understand multi-agency information
Wider context from the report “5. The evidence before the inquest was that where multiple agencies were involved it was fundamental that one agency/person took overall ownership/responsibility to ensure a coordinated and effective approach using regular MDTs to understand the information that all agencies had in their possession and to offer effective support.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue transforming community mental health services toward personalised care planning, named key workers and multidisciplinary assessment and support.
Verbatim wording from the response “With regard to your concern around waiting times for mental health support, we recognise that NHS mental health services are facing increased levels of demand. This means that some people are facing waiting times that are much longer than we would like in order to access the support they need. Through the NHS Long Term Plan, we are expanding and transforming mental health services to help address this. As part of this, the ongoing transformation of community mental health services sees a move away from the use of Care Programme Approach towards high-quality, personalised care and support planning for all service users in line with the NHS England Comprehensive Model of Personalised Care. This includes a named key worker for all service users with a clearer multidisciplinary team approach to both assess and meet the needs of service users.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support NICE guidance improving access to coordinated, multidisciplinary health and social care for people experiencing homelessness.
Verbatim wording from the response “The Department recognises the importance of reducing barriers to services for those experiencing rough sleeping. This is why we supported the development of NICE guidance which provides recommendations on ways to improve access to, and engagement with, health and social care services for people experiencing homelessness. It also provides advice on how commissioners, planners, providers and practitioners across disciplines and agencies can work together as part of a multi-disciplinary team to support and improve outcomes for people experiencing homelessness.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish or expand crisis alternative services, including crisis cafes, safe havens and crisis houses, as alternatives to emergency or psychiatric admission.
Verbatim wording from the response “In terms of crisis care, we have embedded 24/7 urgent mental health helplines in all areas of the country, receiving around 200,000 calls per month, and there are now around 600” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed 24/7 urgent mental health helplines across all areas of the country.
Verbatim wording from the response “In terms of crisis care, we have embedded 24/7 urgent mental health helplines in all areas of the country, receiving around 200,000 calls per month, and there are now around 600” 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 Work towards implementing new waiting-time standards for people requiring mental healthcare in emergency departments and community settings.
Verbatim wording from the response “Between 2018/19 and 2023/24, NHS spending on mental health has increased by £4.7billion in cash terms as compared to the target of £3.4 billion set out at the time of the NHS Long Term Plan. Almost £16 billion was invested in mental health in 2022/23, enabling 3.6 million people to access mental health services, a 10% increase on the previous year. In addition, the NHS is working towards implementing new waiting time standards for people requiring mental healthcare in emergency departments and in the community, to ensure timely access to the most appropriate, high-quality support.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Greater Manchester Integrated Care Board should address the local lack of ownership or responsibility among agencies.
Verbatim wording from the response “Finally, turning to your concern around a lack of overall ownership or responsibility among the different agencies involved. This should be addressed in full by Greater Manchester ICB, as this is a local context, I can confirm that, at a national level, the Government champions joined-up multi-disciplinary approaches. For example, through the 10-year drug strategy, ‘From Harm To Hope’ we have committed to developing a Joint Action Plan to improve mental health treatment for people using drugs and alcohol. The plan focuses on improving join-up between addiction and mental health services, ensuring that everyone can get the care and support they need. It is due to be published later this year and will improve the join up between substance misuse services and mental health services.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department for Levelling Up, Housing and Communities will provide further context on exploitation risks affecting vulnerable homeless young people.
Verbatim wording from the response “I appreciate that a number of your concerns relate to issues around the impact of Mr Mannering-Jones’ homelessness. DHSC has recently published updated guidance for ICPs on the development of integrated care strategies, with specific reference to inclusion health groups and those suffering multiple disadvantage. The updated guidance provides greater clarity on the opportunity for integrated care strategies to consider the wider determinants of” Source location Response from Department of Health and Social Care
Open published response
12 Mar 2024 Peter Beresford · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to clear ambulances from Accident and Emergency departments promptly, limiting ambulance resource utilisation View source Delays in paramedics attending Category 2 calls due to staff and emergency vehicle shortages View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Peter Beresford · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Beresford contacted the North West Ambulance Service with chest pain on 25 September 2023 and was found deceased when an ambulance arrived at his home. The report raised concerns that delays in attending Category 2 calls persisted because of staff and emergency vehicle shortages, and that ambulance resources could not be fully utilised because of delays clearing 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 Failure to clear ambulances from Accident and Emergency departments promptly, limiting ambulance resource utilisation
Wider context from the report “(2) The resources available in the North West Ambulance Service cannot be fully utilised because of the delays in ambulances clearing Accident and Emergency departments caused by the pressure on these departments across the NHS .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 due to staff and emergency vehicle shortages
Wider context from the report “(1) 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 because there are residual staff and emergency vehicle shortages .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Boost paramedic numbers by up to 15,600 under the NHS Long Term Workforce Plan.
Verbatim wording from the response “Regarding staffing capacity, we have made significant investments in the ambulance workforce – the number of NHS ambulance staff and support staff has increased by over 50% since 2010. To help ensure we have the ambulance workforce to meet the future demands on the service, the NHS Long Term Workforce Plan sets out plans to boost the number of paramedics by up to 15,600 to deliver services in ambulance and other care settings.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain additional ambulance capacity funded to expand capacity and improve response times during 2024/25.
Verbatim wording from the response “Your report highlights that NWAS were under high demand at the time of the incident. A primary aim of our 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, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” 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 Maintain the uplift in staffed, permanent hospital bed capacity during 2024/25.
Verbatim wording from the response “why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £1.6 billion over two years to support timely and effective hospital discharge.
Verbatim wording from the response “why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads.” 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 Increase ambulance workforce capacity through investment in NHS ambulance and support staff.
Verbatim wording from the response “Regarding staffing capacity, we have made significant investments in the ambulance workforce – the number of NHS ambulance staff and support staff has increased by over 50% since 2010. To help ensure we have the ambulance workforce to meet the future demands on the service, the NHS Long Term Workforce Plan sets out plans to boost the number of paramedics by up to 15,600 to deliver services in ambulance and other care settings.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the delivery plan for recovering urgent and emergency care services.
Verbatim wording from the response “As the Minister responsible for urgent and emergency care services, I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average across this year. The plan is available at https://www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver new ambulances and specialist mental health vehicles.
Verbatim wording from the response “Your report highlights that NWAS were under high demand at the time of the incident. A primary aim of our 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, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” 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 Scale up and maintain national virtual ward bed capacity above 11,000 beds.
Verbatim wording from the response “why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NWAS is best placed to respond on specific local actions to improve ambulance response times.
Verbatim wording from the response “You have appropriately shared your report and concerns with NWAS who are best placed to respond on the specific actions being taken locally to improve ambulance response times. I note the measures the trust has said are being taken to improve performance, as set out in your report, including the ongoing recruitment of staff and also that performance regionally has been improving.” Source location Response from Department of Health and Social Care
Open published response
7 Mar 2024 Richard Andrew Collins · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 1 Failure of secondary mental health services to revoke driving licences on medical grounds View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Richard Andrew Collins · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Richard Andrew Collins, who had bipolar affective disorder, was struck by an articulated lorry after walking into the eastbound carriageway of the A421 on 9 February 2022, and his death was confirmed despite resuscitation attempts. The report raises concerns that, after his mental health deterioration and hospital admission, his driving fitness and duty to notify the DVLA were not revisited by medical professionals, and that similar missed opportunities may occur nationally.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of secondary mental health services to revoke driving licences on medical grounds
Wider context from the report “2. I have concerns with regard to the following:
i. Whilst considerable work has been undertaken within the secondary mental health services in Dorset, I am concerned that there may be similar issues or missed opportunities nationally within other trusts which could lead to the lack of revocation of driving licences on medical grounds , putting the patients and other road users at risk of death.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ask colleagues in each NHS region to raise awareness of GMC and DVLA driving-fitness guidance with systems and providers.
Verbatim wording from the response “As a result of the concerns highlighted in your Report, colleagues from each of the seven NHS regions will be asked to raise awareness of the GMC and DVLA guidance with their systems and providers.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing GMC and DVLA guidance sets responsibilities for doctors and healthcare professionals regarding fitness to drive and licence revocation.
Verbatim wording from the response “In preparing this response, Departmental officials have made enquiries with NHS England and have been informed that it is not within the remit of NHS England to issue guidance on the revocation of driving licences. As your report states, there is existing national guidance issued by the General Medical Council (GMC) on this issue (Patients’ fitness to drive and reporting concerns to the DVLA or DVA) which outlines the following (section 4):” Source location Response from Department of Health and Social Care
Open published response
7 Mar 2024 Nicola RAYNER · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1 Insufficient bed capacity for informal mental health inpatient admissions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Nicola RAYNER · 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
Nicola Raynor was found hanging on 6 June 2023 and later died at Addenbrookes Hospital from a hypoxic brain injury. The report raises concerns about the lack of available informal mental health inpatient beds locally and nationally, including continuing insufficient bed capacity for patients awaiting admission.
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 bed capacity for informal mental health inpatient admissions
Wider context from the report “Had an informal Mental Health bed been available on the 6th June 2023, and Nicola had been admitted as both she and her psychiatrist had wished, her death would not have occurred.
I am therefore concerned in relation to the overall bed capacity for those patients like Nicola seeking informal inpatient admission.
Nicola’s case is not an isolated one.
Evidence was heard from the Norfolk and Suffolk Foundation Trust, that on the day of the inquest itself (23rd February 2024), the availability of bed provision for informal Mental Health patients had failed to improve at all.
The court heard that on the 23rd February 2024, the Operational Pressure Escalation Level was at its highest level (Four Black) and that at time of Nicola’s inquest, in Suffolk alone, there were 20 patients on a list waiting for an informal inpatient Mental Health bed.
The court heard, that just as on the 6th June 2023, there were no other available informal Mental Health beds anywhere else in the country.
The facts of Nicola’s case mirror those of another tragic Suffolk case, for which I produced a Prevention of Future Death Report in October 2020.
I am therefore concerned, that any measures that may have been taken in the intervening period since October 2020, have neither adequately, or effectively, addressed this clear and continuing local and national risk of future deaths occurring.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest more than £400 million to replace mental health dormitories with ensuite bedrooms, with more than 600 beds already replaced across 34 sites.
Verbatim wording from the response “The strategy is supported by a wide-range of activity the government is funding and that will support people’s mental health. Between 2018/19 and 2023/24, NHS spending on mental health has increased by £4.7bn (in cash terms). This is significantly above the £3.4bn cash terms growth ambition set out at the time of the Long Term Plan. As part of our plans to improve mental health facilities, we are investing over £400 million to eradicate dormitories and give patients the privacy of their own ensuite bedroom - over 600 beds have already been replaced across 34 sites (out of a total of around 1,400 beds across 50 sites).” Source location Response from Department of Health and Social Care
Open published response
29 Feb 2024 Daniel Mark Edward TUCKER · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 7 Inadequate allocation of named nurses to patients View source Continuing accessibility of an online suicide forum to vulnerable people in the UK View source Failure of 999 call grading to trigger a category 1 ambulance response for confirmed ingestion of a potent poison View source Failure to record the named nurse appointed to each patient View source Failure of clinical and nursing staff to complete and utilise ward-specific risk assessments and care plans View source Inadequate delivery of regular and effective named nurse 1:1 sessions View source Insufficient staff skills and knowledge for encouraging engagement with patients View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Daniel Mark Edward TUCKER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel Mark Edward Tucker was detained under the Mental Health Act and admitted to hospital following self-harm and suicidal thoughts, but was discharged on 22 April 2022 despite ongoing concerns about his mental state and risk. He ingested a lethal quantity of a substance later that evening and died. The report identifies concerns about risk assessment and care planning, named-nurse allocation, staff skills in engaging patients, emergency response to confirmed ingestion, and the accessibility of online suicide forums.
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 allocation of named nurses to patients
Wider context from the report “2. Inadequate system of allocating a named nurse to patients and recording the same
I am concerned that, notwithstanding the existence of a clear, appropriate policy requiring the same, the current system of allocating a named nurse and ensuring patients receive regular and effective 1:1 sessions with them are inadequate. I am also concerned that no record is kept of the named nurse appointed to each patient, thus (as in this case) hindering any investigation where issue around the role and actions of that person arises.
The General Manager of Adult Mental Health at the Trust helpfully and frankly acknowledged that the evidence heard at inquest raised questions about the adequacy of the existing system, of which he was not previously aware of. It remains unclear whether Daniel was appointed a Named Nurse who failed to perform that role effectively, or whether there was a failure to appoint such a nurse at all. The General Manager’s view was that under the existing system, it is possible that a named nurse was appointed without their knowledge. While the Ward Manager gave evidence that she would have no confidence Daniel would have known who his named nurse was, even if one was appointed. The inquest heard evidence that named nurse sessions with Daniel during previous admissions had been important opportunities for engagement with staff and had elicited a substantial amount of information pertinent to his risk and treatment. The General Manager assured me that he has already requested an urgent review of the system, but he was unable to provide any further information upon conclusion of the inquest as to what further action, if any, is proposed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Continuing accessibility of an online suicide forum to vulnerable people in the UK
Wider context from the report “1. Continuing accessibility of █████████████████████████████████████████████████████████
Dan was using an online suicide forum, █████████████████████████ Through that forum he was able to engage in discussions with other █████████████████████████ members and obtain information █████████████████████████████████████████████████████████
Notwithstanding the provisions of the Online Safety Act 2023, and apparent attempts to block access to the website, I heard evidence that it remains easily accessible to vulnerable people in the UK . I am concerned that further deaths will occur while this remains the case .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of 999 call grading to trigger a category 1 ambulance response for confirmed ingestion of a potent poison
Wider context from the report “1. I am concerned that confirmed ingestion of ████████ during a 999 call does not trigger a category 1 response from the Ambulance Service
Dan ingested ████████ at around 20:30 on 22 April 2022. His friend informed the 999 call handler that he had done so during a first 999 call at 20:39. That call was correctly graded as requiring a category 2 response, as Dan was both conscious and awake. 14 minutes later, at 20:53, Dan collapsed. His friend’s second 999 call was correctly graded as requiring a category 1 response, as Dan had become unconscious, his breathing agon al. The first ambulance crew arrived at 21:04. Dan went into cardiac arrest at approximately 21:24. Consideration was given by the ambulance crew to ‘scoop and run’ to arrange a rendezvous to administer the necessary “drugs to counter ████████”, but this was no considered longer feasible once Dan had gone into cardiac arrest.
The inquest heard evidence from a consultant toxicologist that even in very small quantities ████████ (or ████████) is lethal; it is a potent poison. I understand it is also, tragically, an increasingly common means of suicide. Mental health professionals who gave evidence expressed deep concern at its easy availability and growing popularity for vulnerable people seeking to end their own lives. The expert toxicological evidence indicated that its acute toxic effects can be rapid (as short as 20 minutes after ingestion, depending on dose) and can quickly become irreversible.
This suggests that almost any case involving the ingestion of ████████ or ████████ is likely to be a time critical life-threatening event . Yet it is does not currently fall within that category for the purposes of grading 999 calls, unless the patient is unconscious or not breathing. While there was no evidence that a category 1 response would have prevented Dan’s death, I believe there is a risk that other deaths will occur if ingestion of ████████ continues to require a category 2 response.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to record the named nurse appointed to each patient
Wider context from the report “2. Inadequate system of allocating a named nurse to patients and recording the same
I am concerned that, notwithstanding the existence of a clear, appropriate policy requiring the same, the current system of allocating a named nurse and ensuring patients receive regular and effective 1:1 sessions with them are inadequate. I am also concerned that no record is kept of the named nurse appointed to each patient , thus (as in this case) hindering any investigation where issue around the role and actions of that person arises.
The General Manager of Adult Mental Health at the Trust helpfully and frankly acknowledged that the evidence heard at inquest raised questions about the adequacy of the existing system, of which he was not previously aware of. It remains unclear whether Daniel was appointed a Named Nurse who failed to perform that role effectively, or whether there was a failure to appoint such a nurse at all. The General Manager’s view was that under the existing system, it is possible that a named nurse was appointed without their knowledge. While the Ward Manager gave evidence that she would have no confidence Daniel would have known who his named nurse was, even if one was appointed. The inquest heard evidence that named nurse sessions with Daniel during previous admissions had been important opportunities for engagement with staff and had elicited a substantial amount of information pertinent to his risk and treatment. The General Manager assured me that he has already requested an urgent review of the system, but he was unable to provide any further information upon conclusion of the inquest as to what further action, if any, is proposed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 and nursing staff to complete and utilise ward-specific risk assessments and care plans
Wider context from the report “1. A continuing practice/culture of minimising the importance of a ward specific risk assessment and care plan
I am concerned that, notwithstanding the existence of a clear, appropriate policy and significant commendable actions by the Trust since Daniel’s death to address this issue, there remain clinical and nursing staff who do not fully recognise or accept the importance of completing and utilising the required risk assessment and care plan . This suggests there may be a persisting training or cultural issue.
The inquest heard evidence that there was (and remains) a clear and robust policy in place which most staff were aware of. This requires a care plan and risk assessment be initiated upon a patient’s admission, completed within 72 hours of admission and updated as necessary during admission. Further, since Dan’s death, the Trust has gone to considerable and commendable lengths to ensure that care plans and risk assessments are in place in every case and to reinforce the requirements of this guidance within the Nursing team; that team hold primary (but not sole) responsibility for creating and updating the risk assessment and care plan document. I also heard that a recent audit found that all current patients had an appropriate care plan in place. The Ward Manager agreed this is “a basic and fundamental part” of any patient’s care. In spite of all of this, an experienced ward nurse and two psychiatrists (a consultant and a registrar) involved in Dan’s care seemed to minimise the practical importance of the required process and documentation , the latter both suggesting they would not routinely consult 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 Inadequate delivery of regular and effective named nurse 1:1 sessions
Wider context from the report “2. Inadequate system of allocating a named nurse to patients and recording the same
I am concerned that, notwithstanding the existence of a clear, appropriate policy requiring the same, the current system of allocating a named nurse and ensuring patients receive regular and effective 1:1 sessions with them are inadequate . I am also concerned that no record is kept of the named nurse appointed to each patient, thus (as in this case) hindering any investigation where issue around the role and actions of that person arises.
The General Manager of Adult Mental Health at the Trust helpfully and frankly acknowledged that the evidence heard at inquest raised questions about the adequacy of the existing system, of which he was not previously aware of. It remains unclear whether Daniel was appointed a Named Nurse who failed to perform that role effectively, or whether there was a failure to appoint such a nurse at all. The General Manager’s view was that under the existing system, it is possible that a named nurse was appointed without their knowledge. While the Ward Manager gave evidence that she would have no confidence Daniel would have known who his named nurse was, even if one was appointed. The inquest heard evidence that named nurse sessions with Daniel during previous admissions had been important opportunities for engagement with staff and had elicited a substantial amount of information pertinent to his risk and treatment. The General Manager assured me that he has already requested an urgent review of the system, but he was unable to provide any further information upon conclusion of the inquest as to what further action, if any, is proposed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 staff skills and knowledge for encouraging engagement with patients
Wider context from the report “3. Inadequate skills/knowledge/training on how to encourage patients to engage
I am concerned that clinical, nursing and/or support staff may not currently have sufficient skills or knowledge in dealing with patients who appear unable or unwilling to engage with staff and/or treatment .
A psychiatrist not involved in Dan’s care gave evidence about the advice he would have given to colleagues on how to seek to assist a patient who, like Dan, was unwilling or unable to engage with staff: first, identify the likely reasons for the patient’s lack of engagement; second, having regard to those reasons, develop plans and strategies to address the specific barriers identified.
I heard little evidence that either of these steps was followed by any of the staff involved in Dan’s care. One barrier was identified (his previous negative experiences on the ward and wish to be transferred to another ward or hospital) but seemingly forgotten after an initial transfer request to the Bed Management team, which was not then followed up. Even with the benefit of hindsight, the doctors, nurses and healthcare assistants involved in Dan’s care seemed unable to offer any insight into the reasons for his difficulties engaging beyond his diagnosis of EUPD or articulate any strategies or techniques that might have helped him overcome them .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with internet service providers, technology companies, social media platforms and expert advisers to tackle harmful pro-suicide forums.
Verbatim wording from the response “The Act provides Ofcom with a robust suite of enforcement powers, including business disruptions measures and significant fines for use in the case of non-compliance. The Government has also worked with internet service providers, tech companies and social media platforms, as well as expert advisors such as the Samaritans, to tackle harmful pro-suicide forums such as this one.” 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 Develop specific training and a protocol for first-party callers in crisis.
Verbatim wording from the response “The MPDS also has protocols for overdose patients as well as those patients with mental health conditions that are suffering any self-harm or suicidal thoughts. Since the time of this call, specific training and a new protocol have been developed specifically for first party callers in crisis.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing intentional-overdose coding and clinician review are considered sufficient; listing every potentially fatal agent would cause over-triage and delays.
Verbatim wording from the response “On your concern regarding ingestion of ████████, Ambulance Emergency Operation Centres (EOCs) use one of two approved triage tools to take 999 emergency calls – Medical Priority Dispatch System (MPDS) or NHS Pathways. At the time of the calls being made to East Midlands Ambulance Service NHS Trust (EMAS) in Mr Tucker’s case, EMAS were users of the protocols within the MPDS. This protocol generates a specific ‘Determinant Code’ for overdose, following the initial assessment of the patient. This then allows the relevant Ambulance Emergency Operation Centre (EOC), in this case that of EMAS, to locally determine and apply a local response mode or ‘Category’. The response modes are underwritten by the NHS England Emergency Call Prioritisation Advisory Group (ECPAG) and sent to NHS Ambulance Service Trusts in England for implementation.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 2 Failure of clozapine packaging and leaflets to warn that combined use with alcohol may cause death View source Lack of guidance on the risk of death from combined clozapine and alcohol use View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sean Benjamin CRAWFORD · 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
Sean Benjamin CRAWFORD died on 18 December 2020 in Darlington from the combined toxic effect of alcohol and clozapine, neither being individually at toxic levels. The principal concern was that available guidance and medication packaging warned about alcohol, sedation and potentially dangerous side effects but did not advise that death could result from this combination.
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 clozapine packaging and leaflets to warn that combined use with alcohol may cause death
Wider context from the report “The circumstances in which Sean came by his death, the combined effects of clozapine with alcohol, seems to be, statistically, very rare. None of the professionals who gave evidence in this case could cite a death with the same cause of death as that suffered by Sean. This said, clozapine is a well-established medication whose side effects are well known. It was originally developed in the 1960s. It is well-known that it requires careful management and monitoring. The side effects are recognised ones and widely known. None of the professional witnesses expressed any lack of familiarity with it or its side effects. One of these side effects is sedation. Likewise, obviously, alcohol is a recognised central nervous system depressant. This is a death from Central Nervous System Depression, consequent to a comparatively high level of clozapine and a comparatively high level of ethanol in the blood – neither individually fatal. It is evident that there is no guidance in any academic literature, British National Formulary, or NICE or MHRA advices on the dangers of death in this scenario. It is noticeable that the leaflet that comes with the Clozaril (clozapine) packages clearly states that it must not be taken with alcohol , and the evidence to me was that the medication comes with a further label, in a similar vein, on the packaging. Neither, however, advises of death being a possibility. All the literature advises that sedation is a potentially dangerous side effect of clozapine. Death from Central Nervous System Depression, over-sedation, is not uncommon. It is often associated with alcohol, and other substance, use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on the risk of death from combined clozapine and alcohol use
Wider context from the report “The circumstances in which Sean came by his death, the combined effects of clozapine with alcohol, seems to be, statistically, very rare. None of the professionals who gave evidence in this case could cite a death with the same cause of death as that suffered by Sean. This said, clozapine is a well-established medication whose side effects are well known. It was originally developed in the 1960s. It is well-known that it requires careful management and monitoring. The side effects are recognised ones and widely known. None of the professional witnesses expressed any lack of familiarity with it or its side effects. One of these side effects is sedation. Likewise, obviously, alcohol is a recognised central nervous system depressant. This is a death from Central Nervous System Depression, consequent to a comparatively high level of clozapine and a comparatively high level of ethanol in the blood – neither individually fatal. It is evident that there is no guidance in any academic literature, British National Formulary, or NICE or MHRA advices on the dangers of death in this scenario. It is noticeable that the leaflet that comes with the Clozaril (clozapine) packages clearly states that it must not be taken with alcohol, and the evidence to me was that the medication comes with a further label, in a similar vein, on the packaging. Neither, however, advises of death being a possibility. All the literature advises that sedation is a potentially dangerous side effect of clozapine. Death from Central Nervous System Depression, over-sedation, is not uncommon. It is often associated with alcohol, and other substance, use.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the coroner’s report with NICE for consideration of its findings in published guidance.
Verbatim wording from the response “should not be taken due to the potential harm to the patient. Departmental officials, however, have shared your report with NICE, so it can consider the impact of your findings on its published guidance.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NICE is responsible for considering whether the report’s findings should affect published guidance on clozapine and alcohol risks.
Verbatim wording from the response “In preparing this response, Departmental officials have made enquiries with National Institute for Health and Care Excellence (NICE). The National Institute for Health and Care Excellence (NICE) is the independent body responsible for developing authoritative, evidence-based guidance on best practice for the health and care system. NICE guidelines are developed by experts based on a thorough assessment of the available evidence and through extensive engagement with stakeholders. Healthcare professionals are expected to take them into full account in their decision making, although it is important to note that NICE guidelines are not mandatory and do not override a clinician’s responsibility to make decisions appropriate to individual patients.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation MHRA is responsible for assessing and potentially improving clozapine product information about drug interactions and associated safety risks.
Verbatim wording from the response “I am aware that the Medicines & Healthcare products Regulatory Agency (MHRA) has provided a response in respect of the key concern you raise in the report. As you will be aware, MHRA is an executive agency of the Department of Health and Social Care (DHSC) with responsibility for the regulation of medicinal products in the UK. The MHRA ensures that medicines are efficacious and acceptably safe, and that any possible side effects which have been reported to occur with use of a medicine are appropriately described in the authorised product information. However, MHRA has recognised in the response that none of the authorised product information specifically mention any risk of death because of the interaction with alcohol.” Source location Response from Department of Health and Social Care
Open published response
14 Feb 2024 Alfie Anthony Kevin Nicholls · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 8 Insufficient school nurse service capacity for identifying health issues and supporting professionals View source Failure to use EHCPs holistically to integrate health and education information View source Unavailability of regular dietitian input for children with eating disorders View source Insufficient publication and guidance on medical emergencies in eating disorders beyond psychiatry View source Failure to establish effective cross-sector strategies for identifying and managing ARFID View source Lack of understanding of ARFID-related medical risk in acute medical settings View source Lack of professional awareness of ARFID and how to approach it View source Failure to consider the health impact of poor and restricted eating in children with autism View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Alfie Anthony Kevin Nicholls · 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
Alfie Anthony Kevin Nicholls, a child with autism and a severely restricted diet, collapsed at home on 17 December 2021 and died at Stepping Hill Hospital despite attempts to resuscitate him. A post-mortem examination found significant malnutrition, and the report identified concerns about poor communication between professionals and the family, limited recognition and understanding of ARFID and medical risk, and insufficient coordinated support and 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 Insufficient school nurse service capacity for identifying health issues and supporting professionals
Wider context from the report “5. The Inquest heard that the school nurse service could play a vital role in identifying health issues and supporting other professionals . This key role was significantly impacted by the high demand on the service and the very high caseloads school nurses working with complex children were being asked to carry nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to use EHCPs holistically to integrate health and education information
Wider context from the report “4. Whilst there was an Education, Health and Care Plan (EHCP) in place for Alfie there was little evidence that EHCPs were being used as a holistic tool to understand the inter relationship between health and education . There was evidence that those writing EHCPs needed to consider a child more holistically for the EHCP to cover all the aspects that it was meant to cover and not just to focus on education .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 regular dietitian input for children with eating disorders
Wider context from the report “6. The role of a dietitian in supporting children with eating disorders could be fundamental in maximising the nutritional value of what they consumed. Demands on the service and a limited understanding of how they could work to support children with disorders such as ARFID (nationally) meant that there was rarely regular input from dieticians .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 publication and guidance on medical emergencies in eating disorders beyond psychiatry
Wider context from the report “7. ARFID, the Inquest was told, could lead to medical emergencies in eating disorders (MEED). The evidence given at the Inquest was that whilst this concept had been the subject of guidance amongst Psychiatrists it had been less publicised and there had been far less guidance by other Royal Colleges . In particular the Inquest was told that MEED needed to be far better understood by medical professionals in acute settings such as Emergency Departments and Paediatrics to avoid a situation where the impact of ARFID and the medical risk it posed was not understood until it was too late.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 effective cross-sector strategies for identifying and managing ARFID
Wider context from the report “2. Evidence before the Inquest was that in addition to there being increased awareness amongst professionals there needed to be strategies within and across Health, Education and Social care to ensure effective strategies were put in place and those with ARFID or at risk of developing ARFID were identified and managed effectively .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 ARFID-related medical risk in acute medical settings
Wider context from the report “7. ARFID, the Inquest was told, could lead to medical emergencies in eating disorders (MEED). The evidence given at the Inquest was that whilst this concept had been the subject of guidance amongst Psychiatrists it had been less publicised and there had been far less guidance by other Royal Colleges. In particular the Inquest was told that MEED needed to be far better understood by medical professionals in acute settings such as Emergency Departments and Paediatrics to avoid a situation where the impact of ARFID and the medical risk it posed was not understood until it was too late .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 awareness of ARFID and how to approach it
Wider context from the report “1. The inquest heard evidence that Avoidant Restrictive Food Intake Disorder (ARFID) was not widely understood by those involved with children and adults who may be impacted by it . That included a lack of awareness of what it was and how to approach it amongst Health, Education and Social Work professionals . The inquest was told that until awareness of it improved then similar situations to that of Alfie could go unrecognised with similar consequences.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the health impact of poor and restricted eating in children with autism
Wider context from the report “3. A feature of the evidence before the Inquest was a normalisation of poor and restricted eating by children with autism . This meant that the impact on their overall health and wellbeing was not considered . Children with autism were measured against each other in relation to their eating with phrases such as “we have children with poorer diets …” being used.
” Open source report
Concerns raised 1 Failure to remove an observed item from the home in response to continued suicidal ideation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Narjit Gill · 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
Narjit Gill died by hanging on 5 May 2023 after recently receiving mental health support and continuing to express suicidal thoughts. The principal concern was the failure to remove an unspecified item seen during a home visit on 3 May 2023, in light of his continued suicidal ideation.
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 remove an observed item from the home in response to continued suicidal ideation
Wider context from the report “(1) Failure to remove ████████ when it was seen on 3 May 2023 by mental health practitioners who visited Mr Gill at his home, in light of his continued expression of suicidal ideation .
” 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 Trust is primarily responsible for addressing the concerns about failing to remove the ladder and noose from the garden.
Verbatim wording from the response “The matters of concern raised are primarily for the Trust to address, and I note that the Coventry and Warwickshire NHS Partnership Trust (CWPT) has addressed your concern in detail in their response. CWPT has identified learning points in their internal learning review and have advised that they have recently updated information packs focussed on ‘Suicide Prevention: Red Flags’ and recommended their internal Risk Assessment Training.” Source location Response from Department of Health and Social Care
Open published response
6 Feb 2024 Mark PRYOR · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1 Lack of sufficient training for health care professionals working in police custody suites View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mark PRYOR · 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
Mark Pryor died at the emergency department of Royal Derby Hospital on 5 September 2020 after suffering an alcohol-withdrawal-related seizure and cardiorespiratory arrest while in police custody. The inquest jury found deficiencies in the health care professionals’ assessment and treatment of his alcohol withdrawal that probably made more than a minimal contribution to his death. The report raises concerns that health care professionals may not receive sufficient training to practise effectively and safely in police custody suites.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficient training for health care professionals working in police custody suites
Wider context from the report “I am concerned that Health Care Professionals (HCPs) may not be receiving sufficient and adequate training to enable them to practice effectively or safely in police custody suites. This is based on the evidence and findings in Mr Pryor’s inquest and my understanding that the training provided by HCRG may be very similar to that given by other providers of HCP police custody services nationally.
Clinical assessment and treatment is provided to police custody detainees by HCPs with the support of an on-call doctor. Typically there will be one HCP per shift. Nationally, HCP services are provided by a number of independent providers under contract to individual police forces. Professionals eligible to be recruited as HCPs (as taken from HCRG personal specification) are registered nurses (general or mental health), or paramedics with a minimum of two years post-qualification with NMC or HCPC registration and ‘nursing experience in the following: A&E, ITU, EAU, SAU, Nurse Practitioner, Practice Nurse, EAU, SAU (other nursing backgrounds will be considered)'.
Current training provided to newly appointed HCPs (by HCRG) consists of shadowing shifts with an experienced HCP, potentially for up to six or eight shifts; a two-day induction course; a medication related course of less than a day which includes a pass or fail test. There is also formal supervision and a three-month probationary period.
The two-day induction course covers the following topics: -
Day 1
Overview of the role of HCPs in custody; Consent, confidentiality and ethics – covering topics including the relevant laws, regulations and regulatory issues, the importance and limitations of concept, assessing capacity, nature of the HCPs dual responsibility and how it affects disclosure of sensitive information. and importance of record keeping; Fitness to detain – covering topics including the need to assess detainees for injuries, illness, and drug and alcohol problems, formulating a care plan in custody to manage risk and identifying those who are not fit to detain who may need alternative support; Fitness to interview / charge/ transfer / release – covering topics including a recap on assessing capacity and assessing, safeguards to prevent the risk of involuntary/false confessions, overview of illnesses that might be worsened by interview and facts to consider when assessing detainees’ fitness to release; Drugs and alcohol is police custody – covering topics including examination features of alcohol and/ or opiate intoxication, examination features of alcohol or opiate withdrawal, key assessment details in the detainee with alcohol dependence, treatment of alcohol / opiate withdrawal in police custody; Mental health in custody - covering topics including the relevant sections of the Mental Health Act, the overlap of learning difficulties with mental health in police custody, the role of liaison and diversion (L&D) teams and the approved mental health professional (AMHP) and when to refer to specialist services; Mental state examination (MSE) – covering topics including purpose of MSE, format of MSE, communicating MSE findings and risk assessments.
Day 2
Forensic science and samples – covering topics including understanding Locard’s Principle, which offences may trigger sample requests, taking non intimate and intimate samples and relevant procedural steps; Traffic Medicine – covering relevant procedures under the Road Traffic Act; Restraint, TASER and irritant sprays – covering an overview of different types of restraint and when a detainee may need hospital following restraint; Documentation of injury – covering how to take history for injuries, how to describe, document and classify injuries; Statement writing – covering topics including overview on preparing a witness statement, format of a witness statement and information required to complete a statement and importance of good clinical notation on the assessment forms provided in custody.
I have reproduced the summary of training, which was given in evidence at the inquest, to illustrate that there are obviously a very extensive number of topics which are listed to be covered.
I find it difficult to see that necessary training can be given within the specified time to equip a paramedic or nurse who is fresh to the custody setting to practice effectively and safely. The inquest heard evidence from the more experienced HCP that when she started, with a different provider some eight years prior, she had six weeks classroom-based training before she commenced full duties as an HCP. The injunction also heard that The Faculty of Forensic & Legal Medicine recommends a five-day induction course for HCPs.
” Open source report
6 Feb 2024 O’Shea Medad Dover · Prevention of Future Deaths report North London
View report summary
Concerns raised 1 Failure of national JRCALC guidance to address conveyance to an obstetrics unit when delivery is not progressing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
O’Shea Medad Dover · 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
O’Shea Medad Dover was delivered after a delayed ambulance response to the mother’s emergency call and was subsequently found to have no foetal heart rate. Resuscitation restored circulation, but the inquest narrative stated that O’Shea was likely subjected to acute severe hypoxia and would likely have survived if the call had been correctly categorised and hospital treatment had occurred earlier. The substantive concern was whether national JRCALC guidance should include advice to convey patients to an obstetrics unit when delivery is not progressing.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of national JRCALC guidance to address conveyance to an obstetrics unit when delivery is not progressing
Wider context from the report “1. Consideration to be given for the national JRCALC guidance to include the London Ambulance Service’s JRCALC Plus recommendation that where delivery is not progressing the patient should be conveyed to an obstetrics unit ;
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for reviewing ambulance-service concerns and taking action lies with NHS England and the Association of Ambulance Chief Executives.
Verbatim wording from the response “My officials have raised these concerns with NHS England (NHSE) as the body responsible for the oversight of the operational delivery of ambulance services nationally. NHS England have responded to confirm that they are working with the Association of Ambulance Chief Executives (AACE) to support their review of the concerns you have raised. I understand that AACE will be responding to you shortly on the action being taken.” Source location Response from DHSC
Open published response
Concerns raised 9 Delays in access to Cognitive Behavioural Therapy with Exposure Response Prevention View source Failure to appoint a care coordinator because of staff shortages View source Unfilled consultant-level vacancies View source Unavailability of hospital beds for informal admission View source Failure to provide sufficient staffing for community mental health team referral screening View source Incorrect information about commissioned OCD treatment View source Insufficient mental health bed capacity View source Long-term difficulties with mental health staff recruitment View source Failure to inform nearest relatives of their Mental Health Act right to request an AMHP case review View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Nicolas Gerasimidis · 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
Nicolas Gerasimidis had a history of mental illness manifesting as OCD and anxiety, which deteriorated despite referrals and treatment arrangements. He was found hanged at his home address on 3 June 2023, and the inquest recorded a conclusion of suicide. Concerns included community mental health referrals being rejected, shortages of care coordinators and consultants, a one-year waiting list for psychological treatment, lack of hospital bed availability, and shortcomings in information provided to his family.
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 access to Cognitive Behavioural Therapy with Exposure Response Prevention
Wider context from the report “The Trust’s Patient Safety Review identified the following concerns:
- When Mr Gerasimidis was referred by his GP to the community mental health team, he was screened out, in part, due to challenging staffing issues;
- No care coordinator was appointed owing to a shortage of staff;
- The Trust had and continues to have vacancies at consultant level;
- The family was wrongly advised the Trust was not commissioned to treat OCD;
- The family was not informed of a nearest relative’s right under the Mental Health Act to request a case review by an AMHP;
- Psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention had a waiting list of one year ;
- In May 2023, when it was felt Mr Gerasimidis required an informal admission into hospital, no beds were available.
The difficulties with staff recruitment and bed availability are long term problems in the Cornwall coroner area. The Patient Safety Review suggests Cornwall has fewer beds for its population than other areas. It is the persistent or recurring nature of these concerns that leads me to believe action should be taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to appoint a care coordinator because of staff shortages
Wider context from the report “The Trust’s Patient Safety Review identified the following concerns:
- When Mr Gerasimidis was referred by his GP to the community mental health team, he was screened out, in part, due to challenging staffing issues;
- No care coordinator was appointed owing to a shortage of staff ;
- The Trust had and continues to have vacancies at consultant level;
- The family was wrongly advised the Trust was not commissioned to treat OCD;
- The family was not informed of a nearest relative’s right under the Mental Health Act to request a case review by an AMHP;
- Psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention had a waiting list of one year;
- In May 2023, when it was felt Mr Gerasimidis required an informal admission into hospital, no beds were available.
The difficulties with staff recruitment and bed availability are long term problems in the Cornwall coroner area. The Patient Safety Review suggests Cornwall has fewer beds for its population than other areas. It is the persistent or recurring nature of these concerns that leads me to believe action should be taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unfilled consultant-level vacancies
Wider context from the report “The Trust’s Patient Safety Review identified the following concerns:
- When Mr Gerasimidis was referred by his GP to the community mental health team, he was screened out, in part, due to challenging staffing issues;
- No care coordinator was appointed owing to a shortage of staff;
- The Trust had and continues to have vacancies at consultant level ;
- The family was wrongly advised the Trust was not commissioned to treat OCD;
- The family was not informed of a nearest relative’s right under the Mental Health Act to request a case review by an AMHP;
- Psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention had a waiting list of one year;
- In May 2023, when it was felt Mr Gerasimidis required an informal admission into hospital, no beds were available.
The difficulties with staff recruitment and bed availability are long term problems in the Cornwall coroner area. The Patient Safety Review suggests Cornwall has fewer beds for its population than other areas. It is the persistent or recurring nature of these concerns that leads me to believe action should be taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of hospital beds for informal admission
Wider context from the report “The Trust’s Patient Safety Review identified the following concerns:
- When Mr Gerasimidis was referred by his GP to the community mental health team, he was screened out, in part, due to challenging staffing issues;
- No care coordinator was appointed owing to a shortage of staff;
- The Trust had and continues to have vacancies at consultant level;
- The family was wrongly advised the Trust was not commissioned to treat OCD;
- The family was not informed of a nearest relative’s right under the Mental Health Act to request a case review by an AMHP;
- Psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention had a waiting list of one year;
- In May 2023, when it was felt Mr Gerasimidis required an informal admission into hospital, no beds were available .
The difficulties with staff recruitment and bed availability are long term problems in the Cornwall coroner area. The Patient Safety Review suggests Cornwall has fewer beds for its population than other areas. It is the persistent or recurring nature of these concerns that leads me to believe action should be taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficient staffing for community mental health team referral screening
Wider context from the report “The Trust’s Patient Safety Review identified the following concerns:
- When Mr Gerasimidis was referred by his GP to the community mental health team, he was screened out, in part, due to challenging staffing issues ;
- No care coordinator was appointed owing to a shortage of staff;
- The Trust had and continues to have vacancies at consultant level;
- The family was wrongly advised the Trust was not commissioned to treat OCD;
- The family was not informed of a nearest relative’s right under the Mental Health Act to request a case review by an AMHP;
- Psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention had a waiting list of one year;
- In May 2023, when it was felt Mr Gerasimidis required an informal admission into hospital, no beds were available.
The difficulties with staff recruitment and bed availability are long term problems in the Cornwall coroner area. The Patient Safety Review suggests Cornwall has fewer beds for its population than other areas. It is the persistent or recurring nature of these concerns that leads me to believe action should be taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Incorrect information about commissioned OCD treatment
Wider context from the report “The Trust’s Patient Safety Review identified the following concerns:
- When Mr Gerasimidis was referred by his GP to the community mental health team, he was screened out, in part, due to challenging staffing issues;
- No care coordinator was appointed owing to a shortage of staff;
- The Trust had and continues to have vacancies at consultant level;
- The family was wrongly advised the Trust was not commissioned to treat OCD ;
- The family was not informed of a nearest relative’s right under the Mental Health Act to request a case review by an AMHP;
- Psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention had a waiting list of one year;
- In May 2023, when it was felt Mr Gerasimidis required an informal admission into hospital, no beds were available.
The difficulties with staff recruitment and bed availability are long term problems in the Cornwall coroner area. The Patient Safety Review suggests Cornwall has fewer beds for its population than other areas. It is the persistent or recurring nature of these concerns that leads me to believe action should be taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health bed capacity
Wider context from the report “The Trust’s Patient Safety Review identified the following concerns:
- When Mr Gerasimidis was referred by his GP to the community mental health team, he was screened out, in part, due to challenging staffing issues;
- No care coordinator was appointed owing to a shortage of staff;
- The Trust had and continues to have vacancies at consultant level;
- The family was wrongly advised the Trust was not commissioned to treat OCD;
- The family was not informed of a nearest relative’s right under the Mental Health Act to request a case review by an AMHP;
- Psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention had a waiting list of one year;
- In May 2023, when it was felt Mr Gerasimidis required an informal admission into hospital, no beds were available.
The difficulties with staff recruitment and bed availability are long term problems in the Cornwall coroner area . The Patient Safety Review suggests Cornwall has fewer beds for its population than other areas . It is the persistent or recurring nature of these concerns that leads me to believe action should be taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Long-term difficulties with mental health staff recruitment
Wider context from the report “The Trust’s Patient Safety Review identified the following concerns:
- When Mr Gerasimidis was referred by his GP to the community mental health team, he was screened out, in part, due to challenging staffing issues;
- No care coordinator was appointed owing to a shortage of staff;
- The Trust had and continues to have vacancies at consultant level;
- The family was wrongly advised the Trust was not commissioned to treat OCD;
- The family was not informed of a nearest relative’s right under the Mental Health Act to request a case review by an AMHP;
- Psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention had a waiting list of one year;
- In May 2023, when it was felt Mr Gerasimidis required an informal admission into hospital, no beds were available.
The difficulties with staff recruitment and bed availability are long term problems in the Cornwall coroner area . The Patient Safety Review suggests Cornwall has fewer beds for its population than other areas. It is the persistent or recurring nature of these concerns that leads me to believe action should be taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to inform nearest relatives of their Mental Health Act right to request an AMHP case review
Wider context from the report “The Trust’s Patient Safety Review identified the following concerns:
- When Mr Gerasimidis was referred by his GP to the community mental health team, he was screened out, in part, due to challenging staffing issues;
- No care coordinator was appointed owing to a shortage of staff;
- The Trust had and continues to have vacancies at consultant level;
- The family was wrongly advised the Trust was not commissioned to treat OCD;
- The family was not informed of a nearest relative’s right under the Mental Health Act to request a case review by an AMHP ;
- Psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention had a waiting list of one year;
- In May 2023, when it was felt Mr Gerasimidis required an informal admission into hospital, no beds were available.
The difficulties with staff recruitment and bed availability are long term problems in the Cornwall coroner area. The Patient Safety Review suggests Cornwall has fewer beds for its population than other areas. It is the persistent or recurring nature of these concerns that leads me to believe action should be taken.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement new waiting-time measures for people requiring mental healthcare in emergency departments and the community.
Verbatim wording from the response “As part of this expansion, the NHS is also committed to improving access to community mental health services. In 2022/23, 288,000 adults with severe mental health problems were able to access support through transformed models of adult community mental health, and by March 2025, it is expected that that number will have increased to 400,000, compared to 2019. In addition, the NHS is working towards implementing new waiting time measures for people requiring mental healthcare in emergency departments and in the community, to ensure timely access to the most appropriate, high-quality support.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide increased mental health investment to expand and transform NHS mental health services.
Verbatim wording from the response “You noted that Mr Gerasimidis was on a lengthy waiting-list to access psychological therapy at the time of his death with ensuing concerns that other patients may have to wait significant lengths of time for care. We recognise that the demand on NHS mental health services has risen significantly, and this means that some people may face waiting times that are much longer than we would like. That is why, through the NHS Long Term plan, the Government is providing record levels of investment and increasing the mental health workforce to expand and transform NHS mental health services in England.” 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 Grow the mental health workforce by an additional 27,000 staff to increase service capacity.
Verbatim wording from the response “You noted that Mr Gerasimidis was on a lengthy waiting-list to access psychological therapy at the time of his death with ensuing concerns that other patients may have to wait significant lengths of time for care. We recognise that the demand on NHS mental health services has risen significantly, and this means that some people may face waiting times that are much longer than we would like. That is why, through the NHS Long Term plan, the Government is providing record levels of investment and increasing the mental health workforce to expand and transform NHS mental health services in England.” 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 ICB considers its commissioned mental health bed capacity appropriate because it matches the national median per 100,000 population.
Verbatim wording from the response “The response from NHS Cornwall and Isles of Scilly Integrated Care Board (the ICB) is focused on your concern around the availability of beds and the transformation work underway more locally. The ICB reports that their commissioning of mental health beds is in line with the national median number of beds per 100,000 population which is 9.45. has advised that its contract with Cornwall Foundation Partnership Trust (CFT) specifies 54 acute mental health beds, however, data shows that there were 47 operational at the date of Mr Gerasimidis' sad death. This remains the situation today. The CFT has 7 closed Acute beds and 6 closed Rehab beds. These beds cannot be reinstated due to environmental issues which are being challenged through CFT Private Finance Initiative contract at the highest level, with the CFT Chief Executive.” 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 Trusts are responsible for ensuring safe staffing levels in the current day-to-day operation of their hospitals.
Verbatim wording from the response “Furthermore, NHS England has instigated the Long-Term Workforce Plan, which is the biggest recruitment drive in health service history and is also an ongoing programme of strategic workforce planning. It includes an ambitious commitments to grow the workforce by significantly expanding domestic education, training and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years. This includes commitments to further grow the Mental Health workforce. 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.” 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 ICB relies on alternative solutions to mitigate the impact of closed mental health beds.
Verbatim wording from the response “The ICB are aware of these bed closures and have been assured by CFT that the impact had been mitigated with alternative solutions” Source location Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Closed acute and rehabilitation beds cannot be reinstated because of environmental issues being challenged through the provider’s contract.
Verbatim wording from the response “The response from NHS Cornwall and Isles of Scilly Integrated Care Board (the ICB) is focused on your concern around the availability of beds and the transformation work underway more locally. The ICB reports that their commissioning of mental health beds is in line with the national median number of beds per 100,000 population which is 9.45. has advised that its contract with Cornwall Foundation Partnership Trust (CFT) specifies 54 acute mental health beds, however, data shows that there were 47 operational at the date of Mr Gerasimidis' sad death. This remains the situation today. The CFT has 7 closed Acute beds and 6 closed Rehab beds. These beds cannot be reinstated due to environmental issues which are being challenged through CFT Private Finance Initiative contract at the highest level, with the CFT Chief Executive.” Source location Response from DHSC
Open published response
29 Jan 2024 Shahzadi Khan · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 8 Failure of out-of-area and private providers to coordinate effectively with local discharge arrangements View source Lack of awareness of menopause as a factor in mental health deterioration View source Inadequate support for women experiencing menopause-related mental health deterioration View source Failure to share clinical notes across different electronic systems View source Failure to establish a clear discharge plan understood by all involved in care View source Use of out-of-area mental health placements limiting family contact View source Lack of understanding of local mental health care pathways by coordinating teams View source Shortage of available mental health beds 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
Shahzadi Khan · 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
Shahzadi Khan was detained under the Mental Health Act after a manic episode with psychotic symptoms and was discharged from an out-of-area private hospital to her family home. Following inadequate discharge planning, communication problems and a failure to arrange the appropriate community care pathway, she deteriorated and took a fatal overdose of prescribed zopiclone at home. The concerns included the effects of out-of-area placements, poor coordination of local care pathways, and insufficient awareness of menopause as a possible factor in mental health deterioration.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of out-of-area and private providers to coordinate effectively with local discharge arrangements
Wider context from the report “1. The inquest heard evidence that a shortage of mental health beds nationally meant that the situation that arose here of a placement out of area many miles from home was not unusual and that private beds were being used on a regular basis due to a shortage of NHS beds. The inquest heard that this meant that there were a number of consequences as a result of all of such placements which could as in Ms Khan’s case impact on a patient and increase the risk they presented. In particular:
• A family could not easily stay in contact and visiting was almost impossible. This meant a patient felt more isolated and their family could not provide information effectively to the treating clinicians.
• Where a non-NHS bed was being used or an out of trust bed was being used notes were not easily shared as different electronic systems were used.
• Out of area trusts/private providers would not be familiar with local arrangements to support discharge and had to rely on local trust teams to put plans in place which could as in this case lead to less effective communication
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 menopause as a factor in mental health deterioration
Wider context from the report “2. There was evidence from her family that her deterioration was in part due to her going through the menopause and that had there been better awareness of this as a factor in mental health deterioration for some women and better support in place, interventions could have taken place at an earlier stage and been more effective.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 support for women experiencing menopause-related mental health deterioration
Wider context from the report “2. There was evidence from her family that her deterioration was in part due to her going through the menopause and that had there been better awareness of this as a factor in mental health deterioration for some women and better support in place , interventions could have taken place at an earlier stage and been more effective .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 clinical notes across different electronic systems
Wider context from the report “1. The inquest heard evidence that a shortage of mental health beds nationally meant that the situation that arose here of a placement out of area many miles from home was not unusual and that private beds were being used on a regular basis due to a shortage of NHS beds. The inquest heard that this meant that there were a number of consequences as a result of all of such placements which could as in Ms Khan’s case impact on a patient and increase the risk they presented. In particular:
• A family could not easily stay in contact and visiting was almost impossible. This meant a patient felt more isolated and their family could not provide information effectively to the treating clinicians.
• Where a non-NHS bed was being used or an out of trust bed was being used notes were not easily shared as different electronic systems were used .
• Out of area trusts/private providers would not be familiar with local arrangements to support discharge and had to rely on local trust teams to put plans in place which could as in this case lead to less effective communication
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 a clear discharge plan understood by all involved in care
Wider context from the report “3. The inquest heard that due to its size the mental health trust covers a number of areas. Each area has its own systems and pathways. Lack of understanding of these pathways by coordinating teams meant that patients were not being moved onto the correct pathway for care. The inquest heard that this was compounded by a lack of awareness by the Trafford HBT of the local pathway for a patient such as Ms Khan and the need for a clear discharge plan to be in place that was understood by all those involved in a patient’s care including her family and mental health care workers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Use of out-of-area mental health placements limiting family contact
Wider context from the report “1. The inquest heard evidence that a shortage of mental health beds nationally meant that the situation that arose here of a placement out of area many miles from home was not unusual and that private beds were being used on a regular basis due to a shortage of NHS beds. The inquest heard that this meant that there were a number of consequences as a result of all of such placements which could as in Ms Khan’s case impact on a patient and increase the risk they presented. In particular:
• A family could not easily stay in contact and visiting was almost impossible . This meant a patient felt more isolated and their family could not provide information effectively to the treating clinicians.
• Where a non-NHS bed was being used or an out of trust bed was being used notes were not easily shared as different electronic systems were used.
• Out of area trusts/private providers would not be familiar with local arrangements to support discharge and had to rely on local trust teams to put plans in place which could as in this case lead to less effective communication
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 local mental health care pathways by coordinating teams
Wider context from the report “3. The inquest heard that due to its size the mental health trust covers a number of areas. Each area has its own systems and pathways. Lack of understanding of these pathways by coordinating teams meant that patients were not being moved onto the correct pathway for care . The inquest heard that this was compounded by a lack of awareness by the Trafford HBT of the local pathway for a patient such as Ms Khan and the need for a clear discharge plan to be in place that was understood by all those involved in a patient’s care including her family and mental health care workers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Shortage of available mental health beds
Wider context from the report “1. The inquest heard evidence that a shortage of mental health beds nationally meant that the situation that arose here of a placement out of area many miles from home was not unusual and that private beds were being used on a regular basis due to a shortage of NHS beds . The inquest heard that this meant that there were a number of consequences as a result of all of such placements which could as in Ms Khan’s case impact on a patient and increase the risk they presented. In particular:
• A family could not easily stay in contact and visiting was almost impossible. This meant a patient felt more isolated and their family could not provide information effectively to the treating clinicians.
• Where a non-NHS bed was being used or an out of trust bed was being used notes were not easily shared as different electronic systems were used.
• Out of area trusts/private providers would not be familiar with local arrangements to support discharge and had to rely on local trust teams to put plans in place which could as in this case lead to less effective communication
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make funding available to support discharge from mental health inpatient settings and reduce out-of-area placements.
Verbatim wording from the response “To improve the issue of out of area placements, and to support adult social care and discharge, up to £2.8 billion has been made available in 2023/24 and £4.7 billion in 2024/25. This can be used to support discharge from mental health inpatient settings, reducing bed occupancy and OAPs. The Department has been working with NHS England and other” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide funding to Mind in Greater Manchester to raise awareness of menopause and its effects on mental health.
Verbatim wording from the response “To raise awareness of menopause for healthcare staff including the effect of menopause on mental health, funding has been given to Mind in Greater Manchester (this is a partnership of five local Minds working together to ensure people experience better mental health and to support people with their mental health to live well and feel valued in their communities and at work). The funding will:” 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 Publish statutory guidance for discharge from all mental health inpatient settings.
Verbatim wording from the response “To improve the issue of out of area placements, and to support adult social care and discharge, up to £2.8 billion has been made available in 2023/24 and £4.7 billion in 2024/25. This can be used to support discharge from mental health inpatient settings, reducing bed occupancy and OAPs. The Department has been working with NHS England and other” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 2 Lack of an appropriate structure to educate and manage people diagnosed with allergies and anaphylaxis View source Failure to provide regular review of allergy, anaphylaxis risk and the benefits of automatic adrenaline injectors View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
James Stuart Atkinson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Stuart Atkinson, who had a known peanut allergy and asthma, died of anaphylaxis after eating a Chicken Tikka Masala pizza containing peanuts from Dadyal Takeaway Restaurant on 10 July 2020. The report identified concerns about the lack of allergen information from the takeaway, the absence of regular allergy reviews, and the failure to locate his Epi-pen during the reaction.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of an appropriate structure to educate and manage people diagnosed with allergies and anaphylaxis
Wider context from the report “The evidence in this case unequivocally established that James was not under regular review for his allergy, risk of anaphylaxis and the benefits of automatic adrenaline injectors.
The report of ████████ (attached) identifies the need for wider consideration of a systematic approach to improving anaphylaxis awareness and management .
The risk of future deaths in the context of allergy/anaphylaxis remains in the absence of an appropriate structure to educate, review and manage those who are diagnosed allergies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide regular review of allergy, anaphylaxis risk and the benefits of automatic adrenaline injectors
Wider context from the report “The evidence in this case unequivocally established that James was not under regular review for his allergy, risk of anaphylaxis and the benefits of automatic adrenaline injectors .
The report of ████████ (attached) identifies the need for wider consideration of a systematic approach to improving anaphylaxis awareness and management.
The risk of future deaths in the context of allergy/anaphylaxis remains in the absence of an appropriate structure to educate, review and manage those who are diagnosed allergies.
” Open source report
22 Jan 2024 Donna Georgina Smith · Prevention of Future Deaths report Teesside and Hartlepool
View report summary
Concerns raised 4 Insufficiently robust methods for detecting worsening conditions in Category 2 calls View source Failure to meet Category 2 ambulance response-time targets View source Failure to detect worsening conditions in Category 2 calls View source Failure to escalate Category 2 calls to Category 1 when conditions worsen View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Donna Georgina Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Donna Georgina Smith suffered chest pain at home on 17 July 2021, deteriorated into cardiac arrest, and died shortly after arriving at hospital. The report identifies concerns that her worsening condition was not recognised or escalated from Category 2 to Category 1, that the methods for detecting deterioration were not sufficiently robust, and that the ambulance response took one hour and six minutes.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust methods for detecting worsening conditions in Category 2 calls
Wider context from the report “2. The methods of detecting worsening conditions in existing category 2 calls are not sufficiently robust (dispatch clinician and numerous call condition).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to meet Category 2 ambulance response-time targets
Wider context from the report “3. The category 2 call target (18minute average response and 95ᵗʰ percentile a 40minute response) was breached and the ambulance arrived 1 hour and 6 minutes after the first call .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to detect worsening conditions in Category 2 calls
Wider context from the report “1. The call handler did not detect a worsening condition and did not escalate the call from Category 2 to category 1.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Category 2 calls to Category 1 when conditions worsen
Wider context from the report “1. The call handler did not detect a worsening condition and did not escalate the call from Category 2 to category 1 .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand and maintain ambulance capacity through additional funding to improve ambulance response times.
Verbatim wording from the response “Your report highlights that NEAS were under high demand at the time of the incident. A primary aim of our 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, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver new ambulances and specialist mental health vehicles to increase ambulance capacity.
Verbatim wording from the response “Your report highlights that NEAS were under high demand at the time of the incident. A primary aim of our 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, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” 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 Publish a delivery plan for recovering urgent and emergency care services, including reducing Category 2 ambulance response times.
Verbatim wording from the response “More broadly, as the Minister responsible for urgent and emergency care services, I recognise the pressures ambulance services are facing and the impact of waiting times for patients. Last January we published our Delivery plan for recovering urgent and emergency care services to” Source location Response from Department of Health and Social Care
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations