9 Feb 2022 Michelle Louise Jennings · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Lack of ownership in the application of referral and discharge policies View source Lack of a mechanism to implement learning on vulnerable people across police forces and prosecuting agencies View source Failure to provide courts with relevant mental health background information View source Failure to share learning on referral and discharge ownership across mental health trusts View source Failure to assess the public interest and mental health vulnerability when making prosecution decisions View source Delays in access to therapy caused by insufficient trained therapist capacity View source See 3 more concerns
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AI-generated summary
Michelle Louise Jennings · 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
Michelle Louise Jennings had a history of suicidal thoughts and contact with mental health services. She died after delays in accessing therapy, prosecution following a railway incident, and problems with communication and case ownership between mental health teams. The report identified concerns about therapy waiting lists, referral and discharge arrangements, and how prosecuting authorities account for mental health vulnerability.
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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 ownership in the application of referral and discharge policies
Wider context from the report “2. The inquest was told that the trust had since Michelle’s death recognised that the lack of ownership created through the application of its referral and discharge policy internally carried an unacceptable risk . Significant changes had been made. However it was unclear if nationally the lesson had been shared and that other mental health trusts had taken similar steps.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism to implement learning on vulnerable people across police forces and prosecuting agencies
Wider context from the report “3. The evidence before the inquest was that there needed to be a clear understanding by all prosecuting authorities of the impact of a prosecution on someone with a complex mental health background such as Michelle. In Michelle’s case the BTP file reviewer (the nature of the offence Michelle faced meant that it was not a CPS lawyer who made the charging decision) had not correctly applied the public interest test and had not considered the mental health/vulnerability of Michelle Jennings as required to. As a consequence a decision was taken to prosecute her without an assessment of the impact on Michelle and her case was dealt with by the Magistrates Court without them being given the full background in relation to her deteriorating mental health. BTP are as a consequence of Michelle’s death taking steps to address how their prosecution teams should deal with the public interest test and gather information where mental health is an issue. However there is no clear mechanism for such learning and changes (to reduce the risk to life) in relation to vulnerable people such as Michelle to be implemented within the other 42 Police forces in England and Wales or within other agencies responsible for prosecuting criminal offences .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 courts with relevant mental health background information
Wider context from the report “3. The evidence before the inquest was that there needed to be a clear understanding by all prosecuting authorities of the impact of a prosecution on someone with a complex mental health background such as Michelle. In Michelle’s case the BTP file reviewer (the nature of the offence Michelle faced meant that it was not a CPS lawyer who made the charging decision) had not correctly applied the public interest test and had not considered the mental health/vulnerability of Michelle Jennings as required to. As a consequence a decision was taken to prosecute her without an assessment of the impact on Michelle and her case was dealt with by the Magistrates Court without them being given the full background in relation to her deteriorating mental health . BTP are as a consequence of Michelle’s death taking steps to address how their prosecution teams should deal with the public interest test and gather information where mental health is an issue. However there is no clear mechanism for such learning and changes (to reduce the risk to life) in relation to vulnerable people such as Michelle to be implemented within the other 42 Police forces in England and Wales or within other agencies responsible for prosecuting criminal offences.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 learning on referral and discharge ownership across mental health trusts
Wider context from the report “2. The inquest was told that the trust had since Michelle’s death recognised that the lack of ownership created through the application of its referral and discharge policy internally carried an unacceptable risk. Significant changes had been made. However it was unclear if nationally the lesson had been shared and that other mental health trusts had taken similar steps .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to assess the public interest and mental health vulnerability when making prosecution decisions
Wider context from the report “3. The evidence before the inquest was that there needed to be a clear understanding by all prosecuting authorities of the impact of a prosecution on someone with a complex mental health background such as Michelle. In Michelle’s case the BTP file reviewer (the nature of the offence Michelle faced meant that it was not a CPS lawyer who made the charging decision) had not correctly applied the public interest test and had not considered the mental health/vulnerability of Michelle Jennings as required to . As a consequence a decision was taken to prosecute her without an assessment of the impact on Michelle and her case was dealt with by the Magistrates Court without them being given the full background in relation to her deteriorating mental health. BTP are as a consequence of Michelle’s death taking steps to address how their prosecution teams should deal with the public interest test and gather information where mental health is an issue. However there is no clear mechanism for such learning and changes (to reduce the risk to life) in relation to vulnerable people such as Michelle to be implemented within the other 42 Police forces in England and Wales or within other agencies responsible for prosecuting criminal offences.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 therapy caused by insufficient trained therapist capacity
Wider context from the report “1. The inquest heard evidence that the backlogs for therapy were such that the waiting list at the time she was assessed as being appropriate for step 4 therapy had a two year wait time. Since that time the waiting period had not decreased and was now between 2 -3 years in both primary and secondary care . This was due to a shortage of trained therapists and demands on the service and was a national issue not specific to the CWP trust.
” 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 Increase the mental health workforce through education, training, recruitment and retention.
Verbatim wording from the response “We know that delivery of our ambitions for mental health services depends on growth of the mental health workforce through education and training, recruitment and retention. As of June 2022 there were 133,573 full time equivalent people working directly on mental health, across NHS trusts and NHS foundation trusts. This is an increase of over 24,400 new staff since March 2016.” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop integrated primary and community mental health services through ring-fenced funding, joined-up working and support delivered through Primary Care Networks.
Verbatim wording from the response “Through the Plan, we are improving joined-up working across the NHS and with other statutory services. Since April 2021, all areas are receiving significant additional, ring-fenced funding to develop fully integrated primary and community mental health services built around Primary Care Networks which includes improved access to psychological therapies, improved physical health care, employment support,” Source location Response from Department of Health and Social Care
Open published response
8 Feb 2022 John David Moore · Prevention of Future Deaths report Essex
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Concerns raised 8 Inadequate communication with primary and secondary care providers View source Failure to formally update Care Plans and Risk Assessments thoroughly and timely View source Failure to recognise the need to escalate patient issues to multidisciplinary meetings or experienced supervisors View source Failure to maintain basic care records, including contacts and failed contacts View source Incomplete and inadequate recording of Care Coordinator supervision sessions View source Insufficient attention to the clinical significance of patient disengagement from services View source Inadequate formal training for Care Coordinators View source Lack of records of the nature, extent and duration of on-the-job or shadowing training View source See 5 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
John David Moore · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John David Moore had a history of homelessness, mental health issues, substance misuse and previous suicide or serious self-harm incidents. He died by suicide on 10 June 2021 while homeless, after no recorded intervention from primary or secondary care since 2020. The report identified concerns about inadequate training and supervision of EPUT Care Coordinators, including shortcomings in record keeping, care planning, communication, recognition of disengagement and escalation of concerns.
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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 Inadequate communication with primary and secondary care providers
Wider context from the report “(2) The evidence in this case, and in other recent inquests heard by me and fellow coroners in this jurisdiction, establishes the following common themes in respect to the inadequate performance of several EPUT Care Coordinators. In my settled view, these themes are (at least to a significant degree) a consequence of inadequate training for the role:
(i) failure to maintain basic record keeping generally and, particularly, with respect to the recording of contacts or, potentially importantly, failed contacts with the deceased in the weeks and months prior to a self-inflicted death;
(ii) a failure to formally up-date Care Plans and Risk Assessments in a thorough and/or timely fashion, or at all;
(iii) inadequate communication with other primary and secondary care providers ;
(iv) consistently, insufficient attention to the potential clinical significance of ‘disengagement’ with services by patients;
(v) failure to recognise the need to raise issues relating to a patient with the Multi-Disciplinary Team Meetings or in supervision with experienced supervisors.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 formally update Care Plans and Risk Assessments thoroughly and timely
Wider context from the report “(2) The evidence in this case, and in other recent inquests heard by me and fellow coroners in this jurisdiction, establishes the following common themes in respect to the inadequate performance of several EPUT Care Coordinators. In my settled view, these themes are (at least to a significant degree) a consequence of inadequate training for the role:
(i) failure to maintain basic record keeping generally and, particularly, with respect to the recording of contacts or, potentially importantly, failed contacts with the deceased in the weeks and months prior to a self-inflicted death;
(ii) a failure to formally up-date Care Plans and Risk Assessments in a thorough and/or timely fashion, or at all ;
(iii) inadequate communication with other primary and secondary care providers;
(iv) consistently, insufficient attention to the potential clinical significance of ‘disengagement’ with services by patients;
(v) failure to recognise the need to raise issues relating to a patient with the Multi-Disciplinary Team Meetings or in supervision with experienced supervisors.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 need to escalate patient issues to multidisciplinary meetings or experienced supervisors
Wider context from the report “(2) The evidence in this case, and in other recent inquests heard by me and fellow coroners in this jurisdiction, establishes the following common themes in respect to the inadequate performance of several EPUT Care Coordinators. In my settled view, these themes are (at least to a significant degree) a consequence of inadequate training for the role:
(i) failure to maintain basic record keeping generally and, particularly, with respect to the recording of contacts or, potentially importantly, failed contacts with the deceased in the weeks and months prior to a self-inflicted death;
(ii) a failure to formally up-date Care Plans and Risk Assessments in a thorough and/or timely fashion, or at all;
(iii) inadequate communication with other primary and secondary care providers;
(iv) consistently, insufficient attention to the potential clinical significance of ‘disengagement’ with services by patients;
(v) failure to recognise the need to raise issues relating to a patient with the Multi-Disciplinary Team Meetings or in supervision with experienced supervisors .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain basic care records, including contacts and failed contacts
Wider context from the report “(2) The evidence in this case, and in other recent inquests heard by me and fellow coroners in this jurisdiction, establishes the following common themes in respect to the inadequate performance of several EPUT Care Coordinators. In my settled view, these themes are (at least to a significant degree) a consequence of inadequate training for the role:
(i) failure to maintain basic record keeping generally and, particularly, with respect to the recording of contacts or, potentially importantly, failed contacts with the deceased in the weeks and months prior to a self-inflicted death;
(ii) a failure to formally up-date Care Plans and Risk Assessments in a thorough and/or timely fashion, or at all;
(iii) inadequate communication with other primary and secondary care providers;
(iv) consistently, insufficient attention to the potential clinical significance of ‘disengagement’ with services by patients;
(v) failure to recognise the need to raise issues relating to a patient with the Multi-Disciplinary Team Meetings or in supervision with experienced supervisors.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Incomplete and inadequate recording of Care Coordinator supervision sessions
Wider context from the report “(3) The evidence received in the course of Mr Moore's inquest disclosed that the record keeping of supervision sessions , where a Care Coordinator might seek or be provided with further advice and support from a senior colleague, was incomplete and inadequate .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 attention to the clinical significance of patient disengagement from services
Wider context from the report “(2) The evidence in this case, and in other recent inquests heard by me and fellow coroners in this jurisdiction, establishes the following common themes in respect to the inadequate performance of several EPUT Care Coordinators. In my settled view, these themes are (at least to a significant degree) a consequence of inadequate training for the role:
(i) failure to maintain basic record keeping generally and, particularly, with respect to the recording of contacts or, potentially importantly, failed contacts with the deceased in the weeks and months prior to a self-inflicted death;
(ii) a failure to formally up-date Care Plans and Risk Assessments in a thorough and/or timely fashion, or at all;
(iii) inadequate communication with other primary and secondary care providers;
(iv) consistently, insufficient attention to the potential clinical significance of ‘disengagement’ with services by patients ;
(v) failure to recognise the need to raise issues relating to a patient with the Multi-Disciplinary Team Meetings or in supervision with experienced supervisors.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 formal training for Care Coordinators
Wider context from the report “(1) EPUT Care Coordinators receive inadequate training for the role . Care Coordinators carry significant responsibilities to coordinate the care provided to an often extremely vulnerable cohort of patients. This responsibility was significantly heightened in the context of the Covid-19 pandemic, and the accompanying periods of ‘lockdown’, when vulnerable and often isolated sufferers of mental health illness and disorders, including those with substance misuse issues, became increasingly isolated and thus increasingly vulnerable. Notwithstanding the imposition of this additional responsibility, the evidence in this and similar coronial investigations has established that Care Coordinators receive no formal training for the role and, at best, are introduced to it via the ‘shadowing’ of colleagues ‘on the job’ . At inquest evidence was provided by an experienced (Band 8a) EPUT Clinical Manager that the lack of formal training for the pivotal role of Care Coordinator within EPUT is one that reflects the same practice in NHS Trusts across the country.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 records of the nature, extent and duration of on-the-job or shadowing training
Wider context from the report “(4) A lack of formal (or even informal) records of the nature, extent or duration of ad hoc ‘on the job’/shadowing’ training , apparently provided to new Care Coordinators.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a refreshed suicide-prevention consensus statement and accompanying guidance supporting frontline information-sharing when someone is at risk of suicide.
Verbatim wording from the response “I would also like to assure you that we are committed to working with the suicide prevention sector, and more broadly, over the coming year to review our 2012 Suicide Prevention Strategy for England. We have worked closely with the Zero Suicide Alliance and Royal Colleges to publish a refreshed consensus statement and accompanying guidance, that will support frontline staff in sharing information if someone is at risk of suicide.” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transform community mental health pathways and establish integrated models across primary care networks in line with published guidance.
Verbatim wording from the response “All integrated care systems have started work to transform their community mental health pathways from 2021/22 in line with published guidance, and ensure the transformed models exist in all primary care networks by 2023/24. These models will enable people with severe mental illness to have greater choice and control over their care and support them to live well in their communities.” 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 specialist mental health provision for people sleeping rough in high-need areas, including a site in Southend, Essex.
Verbatim wording from the response “With regard to mental health and homelessness more generally, in 2019 NHS England announced that, as part of the NHS Long Term Plan, £30 million would be used to establish new specialist mental health provision for people sleeping rough in those parts of England most affected by rough sleeping. The ambition was for new specialist mental health provision for people who sleep rough to be established in 20 high-need areas by 2023/24. The NHS has already met and exceeded this ambition, having now established 23 sites, one of which has opened in Southend, Essex during 2021/22.” Source location Response from Department of Health and Social Care
Open published response
4 Feb 2022 Joy Burgess · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Inability to provide mental health patients with an environment conducive to recovery View source Lengthy waits for access to psychological therapies View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 4
Action
Provide £500 million to expand mental health services, address waiting times, invest in the workforce, and support talking therapies, crisis services and suicide prevention.
Stated completedThe respondent said that this action was complete when they made their response on 7 February 2022. View source
Action
Modernise inpatient mental health environments and eradicate dormitory accommodation to improve patient safety, privacy and dignity.
Stated in progressThe respondent said that this action was in progress when they made their response on 7 February 2022. View source
Action
Work with NHS England on next steps following its consultation on proposed mental health access standards.
Stated in progressThe respondent said that this action was in progress when they made their response on 7 February 2022. View source
Action
Invest £150 million in mental health estate improvements, including safer facilities, accident and emergency-linked services, and new mental health ambulances.
Stated in progressThe respondent said that this action was in progress when they made their response on 7 February 2022. View source See 1 more action
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AI-generated summary
Joy Burgess · 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
Joy Burgess died by suicide on 9 June 2021 as a consequence of multiple injuries. She had complex mental health difficulties, was experiencing deteriorating mental health and thoughts of self-harm, and had left hospital because she found the ward environment busy and extremely noisy. The concerns identified were that mental health wards could be unsuitable for recovery and that patients experienced lengthy waits for psychological therapies.
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 Inability to provide mental health patients with an environment conducive to recovery
Wider context from the report “1. The Court heard evidence that the mental health ward environment could be ‘chaotic’ (in the words of one Consultant Psychiatrist) and that resources and demands on inpatient beds were such that staff were not always able to care for patients in a suitable environment . It is a matter of concern that mental health patients are, on occasion, cared for in an environment which is very obviously not conducive to recovery .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lengthy waits for access to psychological therapies
Wider context from the report “2. The Court heard that patients continue to experience lengthy waits if referred for psychological therapies , both locally and nationally. In the Tameside area, the current average wait was thought to be around one year from referral .
” 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 £500 million to expand mental health services, address waiting times, invest in the workforce, and support talking therapies, crisis services and suicide prevention.
Verbatim wording from the response “The pandemic has had an impact on the mental health and wellbeing of many people, which has caused increased demand for mental health services. In order to help address this, we provided an extra £500 million in 2021/22 to accelerate our expansion plans and address waiting times for mental health services, which will provide more people with the mental health support they need and invest in the NHS workforce. This funding included £110 million to expand adult mental health services - including talking and psychological therapies, implementing the community mental health framework, investment in crisis services and maintaining the delivery of the 24/7 urgent mental health helplines stood up earlier in the pandemic, as well as additional investment in suicide prevention programmes.” 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 Modernise inpatient mental health environments and eradicate dormitory accommodation to improve patient safety, privacy and dignity.
Verbatim wording from the response “We recognise the importance of providing an environment that feels safe and comfortable for people receiving treatment in mental health inpatient care. I understand that in their Concise Investigation Report, the Trust acknowledged that Ms Burgess’s experience on the Taylor ward fell short of the expected standard. You may wish to note that the Government is committed to upgrading the physical environment for inpatient mental health care, and we are already taking steps to modernise inpatient environments and improve patient experience. We are investing more than £400 million over the 4 years up to 2024/25 to eradicate dormitory accommodation from mental health facilities to improve” 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 Work with NHS England on next steps following its consultation on proposed mental health access standards.
Verbatim wording from the response “With regards to those people with more complex mental health needs, who are waiting for treatment, NHS England consulted in 2021 on the potential to introduce five new waiting time standards as part of its clinically-led review of NHS access standards. The proposals included:” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £150 million in mental health estate improvements, including safer facilities, accident and emergency-linked services, and new mental health ambulances.
Verbatim wording from the response “In addition, we are investing £150 million for significant improvements to the mental health estate, including investing in NHS mental health facilities linked to accident and emergency departments, enhancing patient safety in mental health units, and new mental health ambulances.” Source location Response from Department of Health and Social Care
Open published response
3 Feb 2022 Mark Jones · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Backlog in standard referrals causing prolonged outpatient waiting times View source Lack of a standard protocol for routine provision of referral photographs to assist triage View source Inconsistent provision of information in referrals for triage 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
Mark 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
Mark Deardon Jones died at home on 13 November 2020 after a catastrophic haemorrhage at the site of surgery for squamous cell carcinoma of the tongue. Concerns included delays in standard referral pathways and the absence of a national protocol for routinely providing photographs and consistent information to support triage of dental referrals.
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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 Backlog in standard referrals causing prolonged outpatient waiting times
Wider context from the report “1. During the inquest the Court was told that there is a backlog in standard referrals such as Mr Jones being seen . This means that a referral which pre Covid meant a waiting time of approximately 2.5 months for an outpatient appointment now involves a waiting time of approximately 8 months .
2. Mr Jones’ referral was sent in by his dentist to secondary care on the standard referral pathway. On receipt by the secondary care triage team the referral was assessed and based on the information provided remained on the standard referral pathway. The evidence was that a more detailed and better quality referral that included a photograph of the lesion would have probably resulted in his case being moved off the standard pathway. The inquest was told that there is no national standard or protocol in place between dentists and secondary care to provide for the routine provision of photographs to assist in triage. Such a protocol to ensure the provision of photographs by referring dentists in conjunction with more consistent provision of information would, the inquest was told, be helpful in improving the quality of triage and reduce the risk of patients needing urgent care being missed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 standard protocol for routine provision of referral photographs to assist triage
Wider context from the report “1. During the inquest the Court was told that there is a backlog in standard referrals such as Mr Jones being seen. This means that a referral which pre Covid meant a waiting time of approximately 2.5 months for an outpatient appointment now involves a waiting time of approximately 8 months.
2. Mr Jones’ referral was sent in by his dentist to secondary care on the standard referral pathway. On receipt by the secondary care triage team the referral was assessed and based on the information provided remained on the standard referral pathway. The evidence was that a more detailed and better quality referral that included a photograph of the lesion would have probably resulted in his case being moved off the standard pathway. The inquest was told that there is no national standard or protocol in place between dentists and secondary care to provide for the routine provision of photographs to assist in triage . Such a protocol to ensure the provision of photographs by referring dentists in conjunction with more consistent provision of information would, the inquest was told, be helpful in improving the quality of triage and reduce the risk of patients needing urgent care being missed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistent provision of information in referrals for triage
Wider context from the report “1. During the inquest the Court was told that there is a backlog in standard referrals such as Mr Jones being seen. This means that a referral which pre Covid meant a waiting time of approximately 2.5 months for an outpatient appointment now involves a waiting time of approximately 8 months.
2. Mr Jones’ referral was sent in by his dentist to secondary care on the standard referral pathway. On receipt by the secondary care triage team the referral was assessed and based on the information provided remained on the standard referral pathway. The evidence was that a more detailed and better quality referral that included a photograph of the lesion would have probably resulted in his case being moved off the standard pathway. The inquest was told that there is no national standard or protocol in place between dentists and secondary care to provide for the routine provision of photographs to assist in triage. Such a protocol to ensure the provision of photographs by referring dentists in conjunction with more consistent provision of information would, the inquest was told, be helpful in improving the quality of triage and reduce the risk of patients needing urgent care being missed.
” 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 Reinforce good oral cancer referral practice in future communications to dental professionals and commissioners.
Verbatim wording from the response “In the light of your recommendation, the Chief Dental Officer (CDO) will again reinforce the importance of good referral practice in future communications on oral cancer to the dental profession and commissioners. In addition, she has recommended that the NHS cascades similar communication and guidance to NHS general medical practitioners who account for the vast majority of cases referred to Head and Neck centres.” Source location Response from Department of Health and Social Care
Open published response
31 Jan 2022 OSKAR MILES NASH · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 15 Inadequate information and record sharing before EHCP school placements View source Lack of mandatory Autism training for Education and SEN staff View source Lack of training and monitoring programme for EHCP medical advisers View source Failure to establish changed child mental health triage practices in written guidance View source Failure of the threshold of needs document to reflect risks for autistic children View source Lack of specific safeguarding guidance for children with disabilities View source Lack of clarity about schools’ information-sharing powers and duties View source Lack of clinician understanding of EHCP medical advice responsibilities View source Inappropriate closure or referral of child mental health referrals View source Lack of monitoring of access to clinical teams and referral outcomes View source Lack of comprehensive, relevant and mandatory Autism training across state agencies View source Insufficient process, guidance and oversight for effective post-death investigations View source Automatic categorisation of routine referrals as low risk View source Lack of mandatory Autism training for Children’s Services staff View source Lack of mandatory Autism training for child mental health referral triage staff View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
OSKAR MILES NASH · 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
Oskar Nash was 14 when he died by suicide on 9 January 2020 after a history of autism, anxiety, suicidal ideation and self-harm. The report identified failures including the lack of clinical mental-health assessment and support, an inappropriate mainstream-school placement, inadequate information in his Education, Health and Care Plan, and failures by children’s services to assess and respond to his risks. The report also raised ongoing concerns about autism training, referral triage, information sharing, safeguarding guidance and post-death investigations.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate information and record sharing before EHCP school placements
Wider context from the report “I am concerned that there is an ongoing risk that placements of children with EHCPs are being made on the basis of inadequate information and record sharing . On the evidence before me, it was clear that, even if an EHCP were comprehensive and fully updated (which may not be the case), it is unlikely to contain all matters of relevance to the question of a prospective school’s ability to meet the child’s needs.
I was given no good reason why fuller information and record sharing, sufficient to ensure that the prospective school can properly assess its ability to meet the child’s needs, should not take place before any child with an EHCP is placed in a new school. I am concerned that there is no system in place, locally or nationally, to ensure this is achieved by the relevant SEN department for every child with an EHCP . I am also concerned that there is an ongoing lack of clarity as to schools’ powers and duties to share information and documents, and any data protection ramifications this may have.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory Autism training for Education and SEN staff
Wider context from the report “The evidence at the inquest revealed that the staff in the Education / SEN Department, including SEN caseworkers, had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child. I am concerned that there continues to be no requirement for the staff to undertake relevant Autism training on a mandatory basis .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of training and monitoring programme for EHCP medical advisers
Wider context from the report “On the basis of the evidence at the prevention of future deaths hearing, I am concerned that there continues to be a lack of understanding amongst the clinicians currently providing medical advice as part of the EHCP process as to their role in that process. I am further concerned that there is in place no programme for the training or monitoring of these clinicians in relation to these responsibilities .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 changed child mental health triage practices in written guidance
Wider context from the report “I was told that the Standard Operating Procedure manual for the triage of referrals to children’s mental health services is to be updated to reflect the Trust’s new working practices but that this has not yet been done. I am concerned that important changes to the system of work (for example, the vital requirement that a referred child’s records are reviewed before any triaging decision is made and the child/family are spoken to) are not yet established in written guidance .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of the threshold of needs document to reflect risks for autistic children
Wider context from the report “Despite these changes, I remain concerned that the “threshold of needs” document does not adequately and clearly reflect the known risks of mental health difficulties, self-harm, and suicidal ideation for autistic children (given their prevalence in this group of children) and that, consequentially, there is an ongoing risk that an autistic child in these circumstances will be allocated an insufficient level of support , as was the case for Oskar.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 specific safeguarding guidance for children with disabilities
Wider context from the report “I am concerned that “Working Together” does not provide clearer guidance specifically for the safeguarding of children with disabilities, including Autism , and the approach to be taken by agencies to parents and families.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about schools’ information-sharing powers and duties
Wider context from the report “I am concerned that there is an ongoing risk that placements of children with EHCPs are being made on the basis of inadequate information and record sharing. On the evidence before me, it was clear that, even if an EHCP were comprehensive and fully updated (which may not be the case), it is unlikely to contain all matters of relevance to the question of a prospective school’s ability to meet the child’s needs.
I was given no good reason why fuller information and record sharing, sufficient to ensure that the prospective school can properly assess its ability to meet the child’s needs, should not take place before any child with an EHCP is placed in a new school. I am concerned that there is no system in place, locally or nationally, to ensure this is achieved by the relevant SEN department for every child with an EHCP. I am also concerned that there is an ongoing lack of clarity as to schools’ powers and duties to share information and documents , and any data protection ramifications this may have.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 understanding of EHCP medical advice responsibilities
Wider context from the report “On the basis of the evidence at the prevention of future deaths hearing, I am concerned that there continues to be a lack of understanding amongst the clinicians currently providing medical advice as part of the EHCP process as to their role in that process . I am further concerned that there is in place no programme for the training or monitoring of these clinicians in relation to these responsibilities.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inappropriate closure or referral of child mental health referrals
Wider context from the report “However, on the basis of the evidence I heard at the prevention of future deaths hearing, including from a special needs school which has experience of referring its pupils, I am concerned that there is an ongoing risk that some referrals may be inappropriately closed (for example because the child, at an early stage, declines to engage) or inappropriately referred to non-clinical partner agencies . In this context, I am concerned that there is a lack of specific monitoring of what proportion of referred children reach a clinical team and the extent to which the outcomes match the expectations of the referrers (so that any ongoing “barriers” in the system, which may be preventing proper access to the clinical teams, can then be identified and eliminated).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 monitoring of access to clinical teams and referral outcomes
Wider context from the report “However, on the basis of the evidence I heard at the prevention of future deaths hearing, including from a special needs school which has experience of referring its pupils, I am concerned that there is an ongoing risk that some referrals may be inappropriately closed (for example because the child, at an early stage, declines to engage) or inappropriately referred to non-clinical partner agencies. In this context, I am concerned that there is a lack of specific monitoring of what proportion of referred children reach a clinical team and the extent to which the outcomes match the expectations of the referrers (so that any ongoing “barriers” in the system, which may be preventing proper access to the clinical teams, can then be identified and eliminated).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 comprehensive, relevant and mandatory Autism training across state agencies
Wider context from the report “At the prevention of future deaths hearing, I heard evidence of more training being available, but also of an ongoing absence of comprehensive, relevant and mandatory training .
I was told that the National Autism Strategy does not currently include a timetabled commitment for relevant mandatory Autism training to be provided to all state agencies working directly with autistic adults and children .
I am concerned that this poses an ongoing risk to autistic children and their ability to access the services they require for their support, welfare, and safeguarding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 process, guidance and oversight for effective post-death investigations
Wider context from the report “Ineffective review by the child death review processes results in the risk of further deaths in similar circumstances and I am concerned that the local and/or national process, guidance and oversight are insufficient to ensure that an effective post-death investigation , which should not be dependent on the inquest process, is achieved in all cases.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Automatic categorisation of routine referrals as low risk
Wider context from the report “The evidence showed that a referral to the child mental health services is triaged initially as being crisis, urgent, priority or routine. The criteria for crisis, urgent and priority referrals are specific and narrow and, consequently, the great majority of referrals are categorised as routine. I have been told that the routine referrals are automatically categorised as “low risk” . I am concerned about this as it is clear from the evidence that a child may not meet the criteria crisis, urgent or priority but, like Oskar Nash, may nevertheless be at a high or medium risk of harm. The Trust is currently receiving a high volume of referrals and so there is a considerable waiting time for its “routine” cases to be addressed. It seems inevitable, therefore, that there are children in this category who have been wrongly assumed to be at low risk of harm but who, in fact, face a high risk of harm which is currently unrecognised and unmanaged.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory Autism training for Children’s Services staff
Wider context from the report “The evidence at the inquest revealed that the staff in SCC’s Children’s Services Department, including Social Workers and other Team members, had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child. I am concerned that there continues to be no requirement for the staff to undertake relevant Autism training on a mandatory basis .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory Autism training for child mental health referral triage staff
Wider context from the report “The evidence at the inquest revealed that the staff responsible for the triage of referrals to child mental health services had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child. I have been told that the triaging process is now undertaken by an “Access and Advice Team” but I am concerned that there continues to be no requirement for the staff in that Team to undertake relevant Autism training on a mandatory basis .
” Open source report
28 Jan 2022 Mark Anthony Athias · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 7 Failure of managers to detect inadequate monitoring records View source Unavailability of sterile replacement catheters in stock View source Delayed managerial detection of missing handover records View source Failure to detect mistakes in ordering replacement catheters View source Failure to conduct sufficiently frequent checks that required records exist and are preserved View source Inadequate contemporaneous records of fluid intake and output View source Failure to preserve handover records View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mark Anthony Athias · 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 Anthony Athias had multiple physical and mental health issues, including recurring urinary infections and problems with a long-term catheter. After difficulties with his catheter on 2 July 2021, he was admitted to hospital, where his condition deteriorated and he died on 6 July 2021. Concerns included a lack of sterile replacement catheters, inadequate monitoring records, and a missing handover record, with risks arising from deficient record keeping.
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 managers to detect inadequate monitoring records
Wider context from the report “2. The catheter care plan had identified the need for his fluid intake and output to be monitored. The contemporaneous records kept were, however, inadequate. This hindered any assessment of his urinary problems. The managers in the nursing home had not noticed the inadequacy of such records .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 sterile replacement catheters in stock
Wider context from the report “1. The nursing home did not have sterile replacement catheters in stock , despite being aware that Mr Athias had difficulties with his catheter, which had necessitated it being replaced twice in previous weeks. The mistakes made in ordering replacements had not been detected by the managers in the nursing home.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delayed managerial detection of missing handover records
Wider context from the report “3. The handover record for 2 July 2021 was missing, having allegedly been overwritten. The managers in the nursing home did not appreciate this until an Adult Safeguarding Investigation was underway .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 mistakes in ordering replacement catheters
Wider context from the report “1. The nursing home did not have sterile replacement catheters in stock, despite being aware that Mr Athias had difficulties with his catheter, which had necessitated it being replaced twice in previous weeks. The mistakes made in ordering replacements had not been detected by the managers in the nursing home .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 sufficiently frequent checks that required records exist and are preserved
Wider context from the report “4. In order to ensure instructions were complied with, and without checks to ensure the contemporaneous records required to be kept were actually being maintained , there is a risk deficient record keeping could continue .
5. Managers of nursing homes should make checks sufficiently often to ensure the records required to be kept actually exist, and that they are preserved , so as to facilitate an analysis of trends in the medical condition of patients in the care of the nursing home
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 contemporaneous records of fluid intake and output
Wider context from the report “2. The catheter care plan had identified the need for his fluid intake and output to be monitored. The contemporaneous records kept were, however, inadequate . This hindered any assessment of his urinary problems. The managers in the nursing home had not noticed the inadequacy of such records.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 preserve handover records
Wider context from the report “3. The handover record for 2 July 2021 was missing, having allegedly been overwritten . The managers in the nursing home did not appreciate this until an Adult Safeguarding Investigation was underway.
” Open source report
7 Jan 2022 Mrs Surekha Pandharinath Shivalkar · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Failure to use targeted factual communication between surgical and anaesthetic teams during surgery View source Failure to communicate a surgeon's reasons for leaving surgery to the surgical team View source Failure to effectively monitor when a surgeon leaves theatre View source Lack of a system to assess the appropriateness of a surgeon leaving surgery View source Lack of a formal preoperative risk assessment tool requirement View source Failure to record a surgeon's early departure in the surgical notes View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mrs Surekha Pandharinath Shivalkar · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Surekha Pandharinath Shivalkar, aged 78, underwent revision total hip replacement surgery and subsequently developed profound hypotension, multiorgan failure and cardiac arrest, dying despite intensive treatment. Concerns included the absence of a formal preoperative risk assessment tool, poor communication between the surgical and anaesthetic teams, and inadequate systems concerning the senior surgeon’s departure before the operation concluded.
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 use targeted factual communication between surgical and anaesthetic teams during surgery
Wider context from the report “2. Poor communication between the orthopaedic surgical team and the anaesthetist during surgery led to a collective failure to identify a critically ill patient. General and non-specific questions regarding the patient’s welfare passed between the two teams but no targeted questions requiring clear factual responses were asked . Had such questions been put, a different outcome may have arisen.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate a surgeon's reasons for leaving surgery to the surgical team
Wider context from the report “3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team , neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 effectively monitor when a surgeon leaves theatre
Wider context from the report “3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a system to assess the appropriateness of a surgeon leaving surgery
Wider context from the report “3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate , or to effectively monitor when a surgeon leaves theatre.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal preoperative risk assessment tool requirement
Wider context from the report “1. No formal risk assessment tool was adopted to assess preoperative risk prior to Mrs Shivalkar's total hip replacement revision surgery. Despite policy changes at Barts Health NHS Trust since 2018, there remains no requirement to utilise such a tool .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to record a surgeon's early departure in the surgical notes
Wider context from the report “3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure . The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre.
” Open source report
6 Jan 2022 Kyriacos Athanasis · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 6 Lack of emergency department capacity for timely ambulance patient transfer View source Failure to maintain emergency department and inpatient capacity for timely ambulance admissions View source Limited capacity for diagnosis and treatment while patients wait in ambulances View source Insufficient safety checks to reveal the extent of injuries in patients left in ambulances View source Delays in ambulances attending other emergencies View source Reliance on safety checks for patients left in ambulances because of emergency department space delays View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kyriacos Athanasis · 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
Kyriacos Athanasis, an 88-year-old man with frailty and several medical conditions, fell down stairs and sustained an unstable cervical spine fracture. Delays transferring him from an ambulance and diagnosing the fracture were followed by pneumonia, and he died after deteriorating. The principal concerns were emergency department overcrowding, insufficient ambulance patient safety checks, delayed diagnosis and treatment, and resulting risks to patients awaiting ambulance transfer or care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of emergency department capacity for timely ambulance patient transfer
Wider context from the report “(1) Evidence given at the inquest revealed that there was a delay in Mr. Athanasis being transferred from the ambulance into the emergency department at the James Paget hospital as they had no space for him to be transferred into .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain emergency department and inpatient capacity for timely ambulance admissions
Wider context from the report “(4) The Emergency department staff gave evidence that they regularly have too many patients in the department and cannot find space to safely allow ambulances to transfer patients into their care and then leave . The staff at the Trust indicated that they did not consider that locally there were any further steps they could take and gave evidence this was a more complex problem, predominately due to the Trust’s inability to discharge patients who are medically fit to be discharged and occupying much needed beds. This in turn means that they are unable to move patients from the emergency department to beds in the hospital in a timely manner which leads to them not having capacity to admit patients brought in by ambulances . This clearly means that ambulances are delayed and in turn are unable to attend other emergencies in a timely manner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Limited capacity for diagnosis and treatment while patients wait in ambulances
Wider context from the report “(5) Significant local steps have been taken to reduce the risks to patients, but the department is functioning well over their capacity (at the time of the hearing the Trust had 75 patients in a department designed for 40). There are clear risks of future deaths for patients waiting for an ambulance as well as to patients whose diagnosis and treatment is delayed due to limited intervention being available in the back of an ambulance .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient safety checks to reveal the extent of injuries in patients left in ambulances
Wider context from the report “(3) In this instance the mechanism to undertake a safety check was not sufficient to reveal the extent of the injuries Mr. Athanasis had sustained, and this meant there was a delay in diagnosing him with his unstable cervical fracture . This delay in conjunction with other issues more than minimally or trivially contributed to his death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulances attending other emergencies
Wider context from the report “(4) The Emergency department staff gave evidence that they regularly have too many patients in the department and cannot find space to safely allow ambulances to transfer patients into their care and then leave. The staff at the Trust indicated that they did not consider that locally there were any further steps they could take and gave evidence this was a more complex problem, predominately due to the Trust’s inability to discharge patients who are medically fit to be discharged and occupying much needed beds. This in turn means that they are unable to move patients from the emergency department to beds in the hospital in a timely manner which leads to them not having capacity to admit patients brought in by ambulances. This clearly means that ambulances are delayed and in turn are unable to attend other emergencies in a timely manner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Reliance on safety checks for patients left in ambulances because of emergency department space delays
Wider context from the report “(2) As there had been known delays in obtaining space in the emergency department at the Trust senior clinicians undertook a safety check of those patients left in ambulances to assess the urgency and need for a trolley or bed .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide dedicated funding for social care to reduce beds occupied by patients ready for discharge.
Verbatim wording from the response “A key part of the recovery plans is about improving hospital’s patient flow and bed capacity. The recovery plan will deliver 5,000 more staffed, permanent beds and scale up virtual ward beds which are now over 11,000. This increase is backed by £1 billion of dedicated revenue funding and £250m of capital funding. A further £1.6 billion of funding for social care over two years is being provided to reduce the numbers of beds occupied by patients ready to be discharged. These measures will speed up emergency admissions and reduce overcrowding in Emergency Departments enabling ambulances to handover patients more quickly.” 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 additional ambulance funding to expand capacity and deliver new ambulances.
Verbatim wording from the response “We are taking a number of steps to improve ambulance response times. Ambulance trusts are receiving an additional £200 million of funding this year to expand capacity and deliver new ambulances, helping patients receive the treatment they need. We are also delivering 6” 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 5,000 additional staffed permanent hospital beds.
Verbatim wording from the response “A key part of the recovery plans is about improving hospital’s patient flow and bed capacity. The recovery plan will deliver 5,000 more staffed, permanent beds and scale up virtual ward beds which are now over 11,000. This increase is backed by £1 billion of dedicated revenue funding and £250m of capital funding. A further £1.6 billion of funding for social care over two years is being provided to reduce the numbers of beds occupied by patients ready to be discharged. These measures will speed up emergency admissions and reduce overcrowding in Emergency Departments enabling ambulances to handover patients more quickly.” 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 virtual ward capacity beyond its existing level.
Verbatim wording from the response “A key part of the recovery plans is about improving hospital’s patient flow and bed capacity. The recovery plan will deliver 5,000 more staffed, permanent beds and scale up virtual ward beds which are now over 11,000. This increase is backed by £1 billion of dedicated revenue funding and £250m of capital funding. A further £1.6 billion of funding for social care over two years is being provided to reduce the numbers of beds occupied by patients ready to be discharged. These measures will speed up emergency admissions and reduce overcrowding in Emergency Departments enabling ambulances to handover patients more quickly.” 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 six new ambulance hubs to reduce handover delays.
Verbatim wording from the response “We are taking a number of steps to improve ambulance response times. Ambulance trusts are receiving an additional £200 million of funding this year to expand capacity and deliver new ambulances, helping patients receive the treatment they need. We are also delivering 6” 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 Establish Same Day Emergency Care services across every hospital with a major emergency department.
Verbatim wording from the response “In addition, Same Day Emergency Care (SDEC) services will be in place across every hospital with a major emergency department, helping avoid unnecessary overnight stays in hospital. The SDEC model helps to reduce pressure on emergency departments because patients receiving SDEC can be rapidly assessed, diagnosed, and treated without being admitted to a ward, and if clinically safe to do so, will go home the same day their care is provided.” 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 42 new or upgraded hospital discharge lounges to support safe, timely discharge.
Verbatim wording from the response “We are taking a number of steps to improve ambulance response times. Ambulance trusts are receiving an additional £200 million of funding this year to expand capacity and deliver new ambulances, helping patients receive the treatment they need. We are also delivering 6” Source location Response from Department of Health and Social Care
Open published response
5 Jan 2022 James EMMERSON · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 2 Failure to provide AMHP assessment before discharge from section 136 detention View source Ambiguity in guidance on required AMHP assessment under section 136 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
James EMMERSON · 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 Emmerson, known as Jamie, was detained under section 136 of the Mental Health Act on 1 February 2019 but was discharged without being interviewed by an Approved Mental Health Professional. He was later detained at a police custody suite and died by hanging at home on 3 February 2019. The principal concern was confusion in the Code of Practice, which led to an interpretation that an Approved Mental Health Professional assessment was not required before discharge, exposing patients to significant risk including self-harm or suicide.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide AMHP assessment before discharge from section 136 detention
Wider context from the report “1. Confusion generated by the Department of Health Guide “Mental Health Act 1983 Code of Practice” (“The Code”).
The Mental Health Act 1983 is the relevant Act under which persons may be assessed or detained when they are suspected or diagnosed as having one of a number of mental disorders.
Section 136 of the Mental Health Act 1983 is a power which allows police officers to remove a person who is in a place to which the public have access to a place of safety. Many mental health facilities have designated “section 136 suites” where the detained person can be taken for assessment. Jamie was in a public place when his psychiatric needs assessed by police were such that he needed to be taken to a place of safety. He was taken to the section 136 suite at the Luton and Dunstable University Hospital.
Section 136 (2) MHA 1983 provides that “A person removed to or kept at a place of safety under this section may be detained there for ........ the purpose of enabling him to be examined by a registered medical practitioner and to be interviewed by an approved mental health professional and of making any necessary arrangements for his treatment or care”.
“The Code” (s 16.25) states: “The purpose of removing a person to a place of safety in these circumstances is only to enable the person to be examined by a doctor and interviewed by an AMHP, so that the necessary arrangements can be made for the person’s care and treatment.
“The Code” (s16.27) states: “The person should be assessed by a doctor and interviewed by an AMHP as soon as possible after the person is brought to the place of safety.”
Jamie was never examined by an AMPH only by a lone section 12 approved
junior doctor and he was discharged from his s.136.
In answer to the question as to why he was not examined by an AMPH s 16.50 of “The Code” was relied on which states: “If a doctor assesses the person and concludes that the person is not suffering from a mental disorder then the person must be discharged, even if not seen by an AMHP.”
This was interpreted as meaning that assessment by an AMPH was not a required formality. This was a deeply flawed interpretation but it is possible to see where the ambiguity arises.
I was told that this arrangement was “custom and practice” in Bedfordshire and Luton and also in other areas. Whether it was custom and practice or not I consider that the arrangement contravened both the spirit and the letter of the Mental Health Act 1983. It exposed patients to significant risk, including that of self harm or suicide by failing to provide adequate assessment prior to discharge from s. 136 detention. I was told that the position in Bedfordshire and Luton had been regularised by the time of the Inquest but I have no knowledge as to practice in the “other areas” referred to.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in guidance on required AMHP assessment under section 136
Wider context from the report “1. Confusion generated by the Department of Health Guide “Mental Health Act 1983 Code of Practice” (“The Code”).
The Mental Health Act 1983 is the relevant Act under which persons may be assessed or detained when they are suspected or diagnosed as having one of a number of mental disorders.
Section 136 of the Mental Health Act 1983 is a power which allows police officers to remove a person who is in a place to which the public have access to a place of safety. Many mental health facilities have designated “section 136 suites” where the detained person can be taken for assessment. Jamie was in a public place when his psychiatric needs assessed by police were such that he needed to be taken to a place of safety. He was taken to the section 136 suite at the Luton and Dunstable University Hospital.
Section 136 (2) MHA 1983 provides that “A person removed to or kept at a place of safety under this section may be detained there for ........ the purpose of enabling him to be examined by a registered medical practitioner and to be interviewed by an approved mental health professional and of making any necessary arrangements for his treatment or care”.
“The Code” (s 16.25) states: “The purpose of removing a person to a place of safety in these circumstances is only to enable the person to be examined by a doctor and interviewed by an AMHP, so that the necessary arrangements can be made for the person’s care and treatment.
“The Code” (s16.27) states: “The person should be assessed by a doctor and interviewed by an AMHP as soon as possible after the person is brought to the place of safety.”
Jamie was never examined by an AMPH only by a lone section 12 approved
junior doctor and he was discharged from his s.136.
In answer to the question as to why he was not examined by an AMPH s 16.50 of “The Code” was relied on which states: “If a doctor assesses the person and concludes that the person is not suffering from a mental disorder then the person must be discharged, even if not seen by an AMHP.”
This was interpreted as meaning that assessment by an AMPH was not a required formality. This was a deeply flawed interpretation but it is possible to see where the ambiguity arises.
I was told that this arrangement was “custom and practice” in Bedfordshire and Luton and also in other areas. Whether it was custom and practice or not I consider that the arrangement contravened both the spirit and the letter of the Mental Health Act 1983. It exposed patients to significant risk, including that of self harm or suicide by failing to provide adequate assessment prior to discharge from s. 136 detention. I was told that the position in Bedfordshire and Luton had been regularised by the time of the Inquest but I have no knowledge as to practice in the “other areas” referred to.
” Open source report
31 Dec 2021 Jos Tarse-Joy · Prevention of Future Deaths report Greater Manchester South
View report summary
Concerns raised 7 Maternity service layout impeding full patient oversight View source Failure to perform admission CTG monitoring for identified high-risk pregnancies View source Failure to communicate the planned pre-41-week induction pathway View source Lack of explicit flagging of high-risk pregnancies in notes and communication View source Absence of parental support and advocacy during antenatal care and admission View source Lack of clear escalation processes for trainee midwives View source Failure to use falling centile-chart trajectory as a trigger for further checks 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
Jos Tarse-Joy · 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
Jos Tarse-Joy was born by emergency caesarean section at 41 weeks after his high-risk pregnancy was not explicitly identified to his parents or care team, no induction had been arranged, and CTG monitoring was not used on admission. He was born in very poor condition, sustained severe brain damage following hypoxia, and died at Royal Oldham Hospital on 15 December 2020. The principal concerns included communication and documentation failures, lack of appropriate monitoring and induction planning, unclear escalation processes, and wider issues concerning maternity-service layout and national guidance.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Maternity service layout impeding full patient oversight
Wider context from the report “3. The evidence before the inquest was that the layout of maternity services at the trust meant that triage and delivery were on different floors . The trust did have steps in place to alleviate the challenges of this but evidence was that it made it more difficult for full oversight of patients . The inquest was told that this was not unusual across the NHS estate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 perform admission CTG monitoring for identified high-risk pregnancies
Wider context from the report “4. During the inquest it was accepted that CTG monitoring should have taken place at admission given that the pregnancy had been identified as high risk . If that had been satisfactory then it would have been appropriate to consider moving to regular monitoring. However that was not understood by the midwifery team as it was not explicit within the notes . The evidence was that clearer guidance and understanding nationally of when to use an admission CTG would reduce the risk to a baby during labour.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the planned pre-41-week induction pathway
Wider context from the report “2. The inquest heard evidence that the consultant would not have advised that the pregnancy proceed beyond 41 weeks and that an induction of labour would be offered before his mother reached that date. Disjointed lines of communication with the community midwifery team and poor communication with his parents meant that they were all unaware of that . As a consequence there was no plan for an induction of labour in place. The inquest heard that improvements had been made within the trust but poor lines of communication with community teams increased the risk of death of a baby.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 explicit flagging of high-risk pregnancies in notes and communication
Wider context from the report “1. The inquest heard evidence that the pregnancy was considered to be a high risk pregnancy .However the inquest heard that there was no nationally recognised way of flagging this within the notes . The trust have taken steps to be more explicit regarding this following Jos's death. The inquest heard that the consequence of it not being explicit in communication or the notes meant that his parents, the community midwife and the GP were unaware that the pregnancy was considered to be high risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of parental support and advocacy during antenatal care and admission
Wider context from the report “7. The antenatal visits occurred during the national lockdown and meant that his father was not at the antenatal visits or present for the initial examination on admission . This meant that Jos's father was not able to offer support and advocate for his mother during the pregnancy or admission.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clear escalation processes for trainee midwives
Wider context from the report “5. A student midwife was involved in the care. She followed the plan developed with an experienced midwife carefully. There was a lack of clarity regarding the escalation process she needed to follow if she identified problems . The evidence was that to avoid delay it was important that Trusts had clear escalation policies in place to appropriately support trainee midwives .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to use falling centile-chart trajectory as a trigger for further checks
Wider context from the report “6. Jos's position on the centile chart had dropped in the last weeks of the pregnancy. The inquest heard that from a clinician's perspective the guidance nationally was not to look at this but to look at the % weight change between the last weight and the new weight . In hindsight the way he tracked on the centile chart appeared to reflect the challenges the placenta was under and it was unclear why the dropping picture on a centile chart was not a trigger for further checks .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a uniform, interoperable format for maternity records across clinical systems.
Verbatim wording from the response “To improve women's access to maternity records, in June 2021 an additional £52 million was announced to fast track the provision of online maternity records. This backs the long-term plan commitment to ensure everyone has access to their maternity notes and information electronically by 2023/24. An initial component of this was to create an agreed uniform format for the notes both in terms of layout and content. This then has been taken to ensure “interoperability” – that is that the notes will be shared irrespective of clinical system.” Source location Response from DHSC
Open published response
23 Dec 2021 Margaret Rose Toye · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Inaccurate recording of MUST malnutrition risk scores View source Failure to assess all patients for malnutrition risk using the MUST score system 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
Margaret Rose Toye · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Margaret Rose Toye, aged 81, sustained an unwitnessed fall on 10 April 2021, suffered a left neck of femur fracture, underwent surgery on 12 April, and died following a cardiac arrest on 20 April 2021. The principal concern was that she was not assessed for malnutrition using the MUST score system; her records incorrectly recorded a score of 0, and it was considered likely that she would have scored 4, which would have prompted mitigations to maximise her nutritional intake. Contemporary ward audits indicated that one in ten patients were not assessed for malnutrition risk.
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 Inaccurate recording of MUST malnutrition risk scores
Wider context from the report “1. Following admission, Mrs Toye was not assessed for risks of malnutrition by use of the MUST score system. Such an assessment was required for all patients. Erroneously, her notes recorded that she scored 0 on the MUST scale which meant that no other staff members began an assessment throughout her admission . It is likely that during admission Mrs Toye would have scored 4 on a MUST assessment, as such a number of mitigations would have been introduced to maximise her nutritional intake.
2. Contemporary audits of compliance of Must scoring on the ward in question demonstrate that one in ten patients are not being assessed for risks of malnutrition.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to assess all patients for malnutrition risk using the MUST score system
Wider context from the report “1. Following admission, Mrs Toye was not assessed for risks of malnutrition by use of the MUST score system. Such an assessment was required for all patients. Erroneously, her notes recorded that she scored 0 on the MUST scale which meant that no other staff members began an assessment throughout her admission. It is likely that during admission Mrs Toye would have scored 4 on a MUST assessment, as such a number of mitigations would have been introduced to maximise her nutritional intake.
2. Contemporary audits of compliance of Must scoring on the ward in question demonstrate that one in ten patients are not being assessed for risks of malnutrition .
” Open source report
21 Dec 2021 Louise Cooper · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 1 Unavailability of sustained daily supported eating for eating-disorder patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Louise Cooper · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Louise Cooper, who had anorexia nervosa and severe malnourishment, died at home on 16 May 2020 after her health declined. The inquest recorded that she had not received the medical monitoring expected after discharge from an eating disorder service. Concerns included the limited availability of sustained supported eating and whether inadequate monitoring contributed to 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 Unavailability of sustained daily supported eating for eating-disorder patients
Wider context from the report “• Louise was known to have suffered with anorexia nervosa for many years and during that time her treatment had included a number of in-patient admissions at times when her extremely low weight became concerning. Neither Louise nor her Father felt that these admissions were in fact helping her to improve.
• Louise had for some time also received treatment from an eating disorder service. Her treatment had included supported eating whereby once per week a professional would sit with her whilst she ate a meal. She responded positively to this. Indeed, it is of note that when her Father attended our court not long after her death, he commented that had Louise been able to have a professional with her once per day whilst she ate, then the outcome for her may have been different and the costs of providing such a service would have been far less than the significant costs of admitting her for periods of treatment in a hospitals. He described her regular hospital admissions as a “revolving door” which was not helping her.
• The Consultant Clinical Psychologist responsible for her care at the eating disorder service had tried to commission an increase in the level of supported eating for Louise but unsuccessfully. She told the court Louise needed this support at least once per day.
• There will be many patients such as Louise who appear to make minimal if any improvement in a hospital setting but who may benefit – according to the clinicians treating them – from sustained supported eating. If that option is not available, these patients may be left with no realistic chance of any meaningful improvement.
” Open source report
17 Dec 2021 Nichola Jane Lomax · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 16 Under-reporting of eating disorder deaths to the coroner View source Lack of clear responsibility for monitoring and co-ordinating community eating disorder care View source Absence of an acute hospital liaison psychiatry service View source Poor and inaccurate compilation of clinical documentation View source Poor nursing care for patients with eating disorders View source Lack of dissemination and understanding of MARSIPAN guidance among medical professionals View source Lack of appropriate investigation and learning from eating disorder deaths View source Failures and delays in maintaining and re-referring patients on the Priory waiting list View source Unclear Priory referral and admission criteria for medically stable patients with low BMI View source Absence of an allocated consultant psychiatrist for CEDS in Bury and six other Manchester boroughs View source Failure to conduct incident reviews of referral failures View source Failure to closely monitor food intake and purging behaviours View source Absence of pathways for acute clinicians to access specialist eating disorder advice View source Lack of formally commissioned community monitoring provision for moderate- or high-risk eating disorder patients View source Exclusion of patients with BMI below 14 from the Community Eating Disorder Service View source Failure to maintain nutrition and fluid charts View source See 13 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
Nichola Jane Lomax · 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
Nichola Jane Lomax had a long history of an eating disorder and attended hospital several times in 2020 with severe malnutrition and electrolyte imbalance. She died on 3 August 2020 after delays and failings involving hospital treatment, specialist referral, communication, monitoring, nutritional care and access to appropriate services. The report identified concerns about inadequate eating-dis disorder training, access to specialist advice, referral criteria, critical services, community monitoring, nursing care and investigation of deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Under-reporting of eating disorder deaths to the coroner
Wider context from the report “7) Lack of Recognition of the need to Investigate
For National Medical Examiner
It was of concern to the court that the only reason Nichola’s death was referred to HM Coroner was her initial medical cause of death had incorrectly included paracetamol toxicity. It was not until the court investigated this case, that there was any recognition by any of the agencies that there had been failings in the care of Nichola. If this death had not been reported to the Coroner, none of the above failings or the need for learning would have been identified. The court is extremely concerned that there is the real potential for under reporting of such cases and a lack of appropriate investigation to ensure learning is captured so as to prevent future deaths. This is important given the court heard eating disorders have the highest mortality rate of any mental disorder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clear responsibility for monitoring and co-ordinating community eating disorder care
Wider context from the report “3) Referral Criteria for the Priory and Community Eating Disorder Service
For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB
In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14. The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care:
• As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care .
• This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders . It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients.
The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13. The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission.
This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding. Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of an acute hospital liaison psychiatry service
Wider context from the report “4) Lack of Critical Services
For BURY CCG / ICB / GMHSCP
The Court heard evidence that despite FGH having a 24/7 Emergency Department, adherence had not been paid to NICE guidance which recommends the establishment of an Acute Liaison Psychiatry service. In this case the court heard that such a service would have provided continuity of care and psychiatric input. The only available psychiatry input at Fairfield hospital for the acute staff is either within the A&E department where there are psychiatric nurses or using the on-call psychiatrist, this post being on call for all psychiatry matters within the whole of Bury. There is no specific liaison psychiatric service for the Acute Hospital .
The evidence was that there is no Consultant Psychiatrist allocated to the CEDS in Bury or the 6 other boroughs of Manchester. However even though the CEDS is provided by the same mental health trust, it is only one of Manchester that does have an allocated Consultant Psychiatrist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor and inaccurate compilation of clinical documentation
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor nursing care for patients with eating disorders
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care . There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of dissemination and understanding of MARSIPAN guidance among medical professionals
Wider context from the report “1) Inadequate Training of doctors and other medical professionals re eating disorders
For National / NCA / Royal College of Psychiatrists
Over 30 members of the medical profession saw Nichola during her three admissions to FGH in 2020. Of those, only one had knowledge of MARSIPAN and his understanding of MARSIPAN was extremely limited. This is not a question of lack of familiarity by professionals, it reflects a complete absence of any understanding that MARSPAN exists and indeed how to implement it in respect of the emergency treatment of an anorexic patient .
Previous Regulation 28 reports suggests this remains an ongoing concern nationally and MARSIPAN is not being disseminated to practitioners on the ground .
Whilst MARSIPAN can be accessed via a link in the NICE guidance on Eating Disorders. My concern is that Acute Trusts may not have sufficient regard to Guidance issued by Royal College of Psychiatry which is relevant to the medical care which they provide.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate investigation and learning from eating disorder deaths
Wider context from the report “7) Lack of Recognition of the need to Investigate
For National Medical Examiner
It was of concern to the court that the only reason Nichola’s death was referred to HM Coroner was her initial medical cause of death had incorrectly included paracetamol toxicity. It was not until the court investigated this case, that there was any recognition by any of the agencies that there had been failings in the care of Nichola. If this death had not been reported to the Coroner, none of the above failings or the need for learning would have been identified. The court is extremely concerned that there is the real potential for under reporting of such cases and a lack of appropriate investigation to ensure learning is captured so as to prevent future deaths . This is important given the court heard eating disorders have the highest mortality rate of any mental disorder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failures and delays in maintaining and re-referring patients on the Priory waiting list
Wider context from the report “7) Delay in Re-Referral
For GMMH/PRIORY
Due to a misunderstanding following the telephone discussion between the Priory and FGH on 11th June Nichola was clearly removed from the Priory waiting list . This led to confusion for the GP practice who did not know why she had been removed. There was then a delay by the CEDS in re-referring Nichola which meant only one bed being available. This should not have occurred and more worryingly had not been noted as there had been no incident review of this case by either the Priory or the CEDS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unclear Priory referral and admission criteria for medically stable patients with low BMI
Wider context from the report “3) Referral Criteria for the Priory and Community Eating Disorder Service
For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB
In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14. The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care:
• As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care.
• This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders. It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients.
The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13 . The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission.
This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding . Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of an allocated consultant psychiatrist for CEDS in Bury and six other Manchester boroughs
Wider context from the report “4) Lack of Critical Services
For BURY CCG / ICB / GMHSCP
The Court heard evidence that despite FGH having a 24/7 Emergency Department, adherence had not been paid to NICE guidance which recommends the establishment of an Acute Liaison Psychiatry service. In this case the court heard that such a service would have provided continuity of care and psychiatric input. The only available psychiatry input at Fairfield hospital for the acute staff is either within the A&E department where there are psychiatric nurses or using the on-call psychiatrist, this post being on call for all psychiatry matters within the whole of Bury. There is no specific liaison psychiatric service for the Acute Hospital.
The evidence was that there is no Consultant Psychiatrist allocated to the CEDS in Bury or the 6 other boroughs of Manchester . However even though the CEDS is provided by the same mental health trust, it is only one of Manchester that does have an allocated Consultant Psychiatrist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 incident reviews of referral failures
Wider context from the report “7) Delay in Re-Referral
For GMMH/PRIORY
Due to a misunderstanding following the telephone discussion between the Priory and FGH on 11th June Nichola was clearly removed from the Priory waiting list. This led to confusion for the GP practice who did not know why she had been removed. There was then a delay by the CEDS in re-referring Nichola which meant only one bed being available. This should not have occurred and more worryingly had not been noted as there had been no incident review of this case by either the Priory or the CEDS .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 closely monitor food intake and purging behaviours
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of pathways for acute clinicians to access specialist eating disorder advice
Wider context from the report “2) Accessing Specialist Advice
For National, NCA/GMMH/PRIORY
None of the practitioners in Nichola’s case knew how to access specialist eating disorder advice including medical or dietetic advice . There are no pathways to assist acute clinicians in how to access this specialist advice . To this day the clinicians told the Court they would not know where to go other than to try and contact the Priory. The Court heard from the Priory they are not commissioned to provide advice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 formally commissioned community monitoring provision for moderate- or high-risk eating disorder patients
Wider context from the report “5) Community Monitoring of patients with an Eating Disorder
For BURY CCG / NATIONAL / ICB/ GMHSCP
There is a lack of clarity as to whether there is any formally commissioned provision for the monitoring of moderate or high risk Eating Disorder patients within the community . The Court heard from GMHSCP that this was the responsibility of primary care however it was unclear whether this was known by those working in primary care and whether this service had ever been commissioned .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Exclusion of patients with BMI below 14 from the Community Eating Disorder Service
Wider context from the report “3) Referral Criteria for the Priory and Community Eating Disorder Service
For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB
In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14 . The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care:
• As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care.
• This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders. It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients.
The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13. The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission.
This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding. Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain nutrition and fluid charts
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June . There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information.
” Open source report
10 Dec 2021 Edward Cockburn · Prevention of Future Deaths report Newcastle upon Tyne
View report summary
Concerns raised 5 Lack of a procedure to record and audit SafeCare training delivery and efficacy View source Failure to provide SafeCare system training to relevant staff View source Failure to ensure staff awareness of the Standard Operating Procedure for Enhanced Care/Observation View source Unsafe positioning of window restrictor fixings on pivot-window sills View source Failure to communicate changes in window restrictor fixing guidance to hospital trusts View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Edward Cockburn · 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
Edward Cockburn died after falling from an upper-storey window in a sluice room at Sunderland Royal Hospital on 15 March 2020, suffering injuries from which he later died. The report identified failures in enhanced-care assessments and observations, an unsecured sluice-room door, a failed window restrictor fixing, and significantly substandard staffing. It also raised concerns about staff training and the communication of updated window-restrictor fitting guidance.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a procedure to record and audit SafeCare training delivery and efficacy
Wider context from the report “Staff appeared to be unaware of the Trusts Standard Operating Procedure in relation to Enhanced Care/Observation. Training at that time had not been given to relevant members of staff in connection with the SafeCare system. Whilst training and information had been cascaded there was no procedure in place in relation to any training that could record and thereafter audit the efficacy of that system with particular regard to when the training was delivered and by whom and to whom it was delivered .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 SafeCare system training to relevant staff
Wider context from the report “Staff appeared to be unaware of the Trusts Standard Operating Procedure in relation to Enhanced Care/Observation. Training at that time had not been given to relevant members of staff in connection with the SafeCare system. Whilst training and information had been cascaded there was no procedure in place in relation to any training that could record and thereafter audit the efficacy of that system with particular regard to when the training was delivered and by whom and to whom it was delivered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff awareness of the Standard Operating Procedure for Enhanced Care/Observation
Wider context from the report “Staff appeared to be unaware of the Trusts Standard Operating Procedure in relation to Enhanced Care/Observation. Training at that time had not been given to relevant members of staff in connection with the SafeCare system. Whilst training and information had been cascaded there was no procedure in place in relation to any training that could record and thereafter audit the efficacy of that system with particular regard to when the training was delivered and by whom and to whom it was delivered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unsafe positioning of window restrictor fixings on pivot-window sills
Wider context from the report “The fixing was attached to the sill of the window in accordance with fitting instructions issued by Jacklok and dated July 2017. Subsequent to the installation a data sheet was issued indicating that the fixing should be attached to the window frame only. This change in data/guidance was not highlighted to South Tyneside and Sunderland NHs Trust and presumably other hospital trusts. The position of the fixing on the sill enabled the restrictor to be more readily defeated bearing in mind this was a pivot window
Jacklok have been requested to take action as follows
(a) To ensure that the guidance is changed clarify the necessity to attach the fixing to the frame and proximity to the points of pivot
(b) To ensure that this is effectively communicated to and highlighted with all NHS Trusts and other relevant users using the Jackloc window restrictor system
The relevant Department guidance is Health Building Note 00-10Part D Windows and Associated Hardware
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate changes in window restrictor fixing guidance to hospital trusts
Wider context from the report “The fixing was attached to the sill of the window in accordance with fitting instructions issued by Jacklok and dated July 2017. Subsequent to the installation a data sheet was issued indicating that the fixing should be attached to the window frame only. This change in data/guidance was not highlighted to South Tyneside and Sunderland NHs Trust and presumably other hospital trusts. The position of the fixing on the sill enabled the restrictor to be more readily defeated bearing in mind this was a pivot window
Jacklok have been requested to take action as follows
(a) To ensure that the guidance is changed clarify the necessity to attach the fixing to the frame and proximity to the points of pivot
(b) To ensure that this is effectively communicated to and highlighted with all NHS Trusts and other relevant users using the Jackloc window restrictor system
The relevant Department guidance is Health Building Note 00-10Part D Windows and Associated Hardware
” Open source report
3 Dec 2021 Alexander George Theodossiadis · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 10 Absence of clear instructions on the need for timely lumbar puncture in suspected meningitis View source Failure to communicate identified falls risk to the receiving ward View source Failure to assess falls risk in confused hospital patients View source Failure to obtain sufficient information to assess appointment urgency and priority View source Absence of a clear pathway to an appropriate treatment location View source Absence of clear national leadership on lumbar puncture practice in meningitis View source Failure to provide written handover instructions or briefing notes during hospital transfer View source Absence of directions specifying action timetables for life-threatening conditions View source Insufficiently frequent refresher training for GP receptionists View source Failure to provide a nurse escort during transfer of severely unwell and confused patients View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alexander George Theodossiadis · 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
Alexander George Theodossiadis, aged 25, died in hospital on 28 January 2020 after treatment for bacterial meningitis, a fall from a hospital bed, and a resulting head injury. Concerns included difficulty obtaining a timely GP appointment and insufficient symptom assessment, inadequate hospital transfer handover and care planning, uncertainty about meningitis management, and failure to assess or communicate his risk of falling.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of clear instructions on the need for timely lumbar puncture in suspected meningitis
Wider context from the report “(2) Mr Theodossiadis remained in A&E for some 10 hours in total, despite the nature of his condition. Concern was expressed at the Inquest in relation to firstly, the absence of clear instructions regarding the need for a lumbar puncture within four hours of admission ; secondly, a clear pathway to an appropriate treatment location; thirdly, any directions specifying the timetable in which action was required in response to a life-threatening 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 communicate identified falls risk to the receiving ward
Wider context from the report “(4) Despite spending 10 hours in A&E and displaying increasing signs of confusion he was seen to be trying to get off his hospital bed which created a risk of falls, no assessment of the falls risk was carried out. In consequence, the receiving ward J27 at St James’s University Hospital, Leeds were not forewarned of the risk of falls . He fell from his hospital bed within approximately 10 minutes of being placed in a side room on his own.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to assess falls risk in confused hospital patients
Wider context from the report “(4) Despite spending 10 hours in A&E and displaying increasing signs of confusion he was seen to be trying to get off his hospital bed which created a risk of falls, no assessment of the falls risk was carried out . In consequence, the receiving ward J27 at St James’s University Hospital, Leeds were not forewarned of the risk of falls. He fell from his hospital bed within approximately 10 minutes of being placed in a side room on his own.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain sufficient information to assess appointment urgency and priority
Wider context from the report “(1) The Inquest heard evidence that when Mr Theodossiadis sought an appointment with a GP, he was only able to get one in three weeks time . He did not venture any details of his symptoms. Nor, however, did the GP’s receptionist probe to obtain any information which would help to assess the urgency of the situation or the priority to be given to his request . Within six days of this telephone call, Mr Theodossiadis was irretrievably overwhelmed with a meningitis infection.
(2) GP receptionists must strike a difficult balance between respecting medical confidence and obtaining sufficient information to enable a judgement to be made in relation to access to medical help. In the case of fast-moving medical conditions such as meningitis afflicting otherwise healthy young people the Inquest heard concerns expressed that refresher training was regularly required but may not be provided with sufficient frequency to maintain vigilance at this important interface between patients and clinicians.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of a clear pathway to an appropriate treatment location
Wider context from the report “(2) Mr Theodossiadis remained in A&E for some 10 hours in total, despite the nature of his condition. Concern was expressed at the Inquest in relation to firstly, the absence of clear instructions regarding the need for a lumbar puncture within four hours of admission; secondly, a clear pathway to an appropriate treatment location ; thirdly, any directions specifying the timetable in which action was required in response to a life-threatening 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 Absence of clear national leadership on lumbar puncture practice in meningitis
Wider context from the report “(3) The Inquest heard evidence that practice differs nationally on the need for a lumbar puncture in cases of meningitis . The absence of clear leadership on this issue nationally does not assist clinicians who may encounter this relatively rare, but serious 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 provide written handover instructions or briefing notes during hospital transfer
Wider context from the report “(1) Evidence was taken at the Inquest which indicated Mr Theodossiadis was moved from one hospital within the Trust to another, close to midnight on 25th January 2020. Despite being severely unwell with bacterial meningitis and in a confused state he was not accompanied by a nurse escort, nor was any written handover instruction or briefing note provided for the nurses receiving him , in breach of the prevailing Trust handover guidance .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of directions specifying action timetables for life-threatening conditions
Wider context from the report “(2) Mr Theodossiadis remained in A&E for some 10 hours in total, despite the nature of his condition. Concern was expressed at the Inquest in relation to firstly, the absence of clear instructions regarding the need for a lumbar puncture within four hours of admission; secondly, a clear pathway to an appropriate treatment location; thirdly, any directions specifying the timetable in which action was required in response to a life-threatening 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 Insufficiently frequent refresher training for GP receptionists
Wider context from the report “(1) The Inquest heard evidence that when Mr Theodossiadis sought an appointment with a GP, he was only able to get one in three weeks time. He did not venture any details of his symptoms. Nor, however, did the GP’s receptionist probe to obtain any information which would help to assess the urgency of the situation or the priority to be given to his request. Within six days of this telephone call, Mr Theodossiadis was irretrievably overwhelmed with a meningitis infection.
(2) GP receptionists must strike a difficult balance between respecting medical confidence and obtaining sufficient information to enable a judgement to be made in relation to access to medical help. In the case of fast-moving medical conditions such as meningitis afflicting otherwise healthy young people the Inquest heard concerns expressed that refresher training was regularly required but may not be provided with sufficient frequency to maintain vigilance at this important interface between patients and clinicians.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 nurse escort during transfer of severely unwell and confused patients
Wider context from the report “(1) Evidence was taken at the Inquest which indicated Mr Theodossiadis was moved from one hospital within the Trust to another, close to midnight on 25th January 2020. Despite being severely unwell with bacterial meningitis and in a confused state he was not accompanied by a nurse escort , nor was any written handover instruction or briefing note provided for the nurses receiving him, in breach of the prevailing Trust handover guidance.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a five-year General Practice Development Programme supporting practice capacity and capabilities.
Verbatim wording from the response “The 2016 General Practice Forward View strategy² provided support for practices to build the capacity and capabilities required to meet patients’ needs. As part of the GP Forward View, the five-year General Practice Development Programme was established. It included total funds of £45 million for allocation by Clinical Commissioning Groups to general practices for training of reception and clerical staff to undertake active signposting and document management. The active signposting training included an expectation for receptionists to be skilled and confident in sensitively ascertaining the nature of the patient’s need and exploring with them safe and appropriate options, including sources of advice and support outside the practice as well as within.” 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 Care Quality Commission is responsible for assessing whether practice staff have suitable qualifications, skills, knowledge, experience and training.
Verbatim wording from the response “Under general practice contract arrangements, it is ultimately the responsibility of practices/contract holders to determine what training staff need and ensure that their staff are appropriately trained to a level that keeps staff safe and meets the needs of patients using the service. The British Medical Association has guidance to help general practitioners and practice managers make informed decisions about what mandatory and statutory training general practice staff should do. The regulator, the Care Quality Commission, is the appropriate body that considers whether practice staff have the right qualifications, skills and knowledge and experience to do their job, how the practice identifies the learning needs of staff, and whether they have adequate training to meet the learning needs.” 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 General practices and contract holders are responsible for determining staff training needs and ensuring staff are appropriately trained.
Verbatim wording from the response “Under general practice contract arrangements, it is ultimately the responsibility of practices/contract holders to determine what training staff need and ensure that their staff are appropriately trained to a level that keeps staff safe and meets the needs of patients using the service. The British Medical Association has guidance to help general practitioners and practice managers make informed decisions about what mandatory and statutory training general practice staff should do. The regulator, the Care Quality Commission, is the appropriate body that considers whether practice staff have the right qualifications, skills and knowledge and experience to do their job, how the practice identifies the learning needs of staff, and whether they have adequate training to meet the learning needs.” Source location Response from Department of Health and Social Care
Open published response
26 Nov 2021 Felicity Jane Clough · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Lack of accessibility to records held by different healthcare trusts View source Failure of Emergency Department staff to access vital pre-admission and paramedic records View source Lack of access by other police forces to information held on individual police force systems 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
Felicity Jane Clough · 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
Felicity Jane Clough was taken to hospital on 24 November 2019 after being prescribed Tramadol, discharged during the early morning, and later found collapsed and unresponsive in a field. The concerns included limited information-sharing between healthcare trusts and police forces, and the failure to consistently review paramedic records containing potentially critical information at Yeovil District Hospital.
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 accessibility to records held by different healthcare trusts
Wider context from the report “i. There could be future deaths nationally due to the lack of accessibility to records held by different healthcare trusts . I would request consideration is given to the sharing of records between healthcare trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of Emergency Department staff to access vital pre-admission and paramedic records
Wider context from the report “iii. I have concerns that future deaths could occur at Yeovil District hospital due to the missing of vital information within the pre admission documentation due to the fact that the staff within the Emergency Department at Yeovil District Hospital are not always accessing admission documentation, especially the paramedic records when a person is brought into the Accident and Emergency department. I request that consideration is given to issuing further guidance to remind staff of the need to review this documentation or amending the current policy in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of access by other police forces to information held on individual police force systems
Wider context from the report “ii. I have concerns that future deaths could occur due to the lack of access to information held on individual Police force systems by other forces , especially neighbouring forces who may both have contact with individuals. Whilst I understand there is some work being done on a regional basis to address this, I would request that the issue is considered nationally as to how information held on all Police systems, not just the Police National Database, can be shared to assist in the management and assessment of individuals and the risk they pose to themselves or others.
” Open source report
25 Nov 2021 Marshall Metcalfe and Jane Ireland · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 1 Failure of social care to remain involved throughout mental health admissions 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
Marshall Metcalfe and Jane Ireland · 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
Marshall Metcalfe was transferred to hospital after sustaining catastrophic injuries on 7 May 2020, where his death was verified. Jane Ireland was found deceased at home on 7 June 2020, after the death of her seventeen-year-old son; the report records toxic effects, fatty liver disease and bronchopneumonia in relation to her death, while her intent could not be established. The principal concern was the lack of Children’s Social Care involvement in Marshall’s discharge planning and the potential future risk arising when social care cases are closed during mental health admissions and require re-referral before discharge.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of social care to remain involved throughout mental health admissions
Wider context from the report “The court heard that when Marshall was in the mental health facility during what was his 2nd admission, a decision was made to discharge him from children’s social care. He had been supported as a Child in Need (under section 17, Children Act 1989) for 28 months, and this continued for a large part of that admission until 14/10/19. In September 2019, a decision had been taken by Children’s Social Care to cease their involvement as no role could be identified for a statutory social worker at that time. Any home leave had been suspended indefinitely, and there were no definite plans for Marshall to be discharged. However, a request was made that in the event the decision about home leave were to change, or if discharge was to be considered likely for Marshall, then Children’s Social Care would again have a role and a re-referral should be made.
In fact, Marshall was discharged on 06/01/20, there being no evidence before the court that such a re-referral had in fact been received by Children’s Social Care by then and it follows there had been no social worker input into Marshall’s discharge planning .
At the inquest, the court received evidence [from Marshall’s Responsible Clinician, Consultant Child & Adolescent Psychiatrist, Dr ████████] that in his experience when patients are admitted to the facility Children’s Social Care will close their case for the patient, and that when the patient is later ready for discharge a re-referral becomes necessary . He also reminded the court that throughout a patient’s admission, consideration is being given to discharge in line with the recommendation of NHS England that all admissions should be kept as short as possible and the expectation that there should be discussion about discharge at every Care Programme Approach (CPA) meeting.
Another witness, ████████, a former Inpatient Social Worker at the facility with 25 years of experience as an Approved Mental Health Professional, told the court that in his view when such a re-referral does become necessary it is like “starting from scratch” and causes immense problems during Trusting therapeutic relationships with young people. He felt that there should be continual input from social care during the patient’s admission , and that in the event that there has been no social worker input into a patient’s discharge this raises the risk for that person once they leave the facility.
I also instructed Dr ████████, a Consultant Child and Adolescent Psychiatrist, to provide an independent expert opinion on the care provided to Marshall. In her evidence she shared the concerns of Dr ████████ and ████████ and described this as “a wider issue” that was not confined to this case.
The issue that I raise is as follows: I share ████████ concern, echoed by Dr ████████, and ideally social care not closing their case, but remaining involved throughout a patient’s admission would be helpful . It may be that they would play a minor role, if any, whilst the patient remains in hospital until discharge is felt to be a genuine prospect, but once their input does become necessary they would be more able to respond quickly and to actively participate in discharge planning without the need to wait for the re-referral process to be carried out , thereby ensuring that the effectiveness of role played by social care in discharge planning is not compromised.
In Marshall’s case, I found that there was no evidence that shortcomings in relation to discharge had materially contributed to his death, but I feel that this issue does pose a risk of deaths in the future, and that it is my duty to write this report.
” Open source report
25 Nov 2021 Dr Malcolm Dixon · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure of electronic care records to preserve auditable timestamps and record actual entry times View source Lack of standardised observation charts and completion rules on mental health wards View source Lack of professional documentation requirements for unregistered ward staff 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
Dr Malcolm Dixon · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Dr Malcolm Dixon became unwell in autumn 2019 with what was later diagnosed as a severe depressive illness and was admitted as an informal, voluntary patient to Priory Hospital, Altrincham. He died there on 29 December 2019 following an impulsive act undertaken in the context of severe mental illness. Concerns included inaccurate observation records, electronic care-record timestamps being overwritten, and the absence of professional documentation requirements for some unregistered staff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of electronic care records to preserve auditable timestamps and record actual entry times
Wider context from the report “2. For similar reasons, it is a matter of concern that automatic time-stamps generated by electronic care records systems can be overwritten by users without the corresponding record showing clearly that this has happened , whilst also recording of the actual time an entry has been made .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of standardised observation charts and completion rules on mental health wards
Wider context from the report “1. Given the particular importance of documented observations being taken at specific intervals on mental health wards, it is a matter of concern that standardised observation charts (together with accompanying standard rules as to how they should be completed) are not in use across these settings both in the NHS and private sectors ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 documentation requirements for unregistered ward staff
Wider context from the report “3. It is a matter of concern that, where record keeping on a ward is undertaken by unregistered staff such as Nursing Assistants and Healthcare Assistants, such individuals are not subject to professional requirements in respect of documentation , such as those which exist for doctors and nurses.
” Open source report
22 Nov 2021 Barrie Keith Housby · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 1 Shortage of staff for required patient care tasks 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
Barrie Keith Housby · 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
Barrie Keith Housby, a hospital patient at high risk of falls, left his bed while the staff member assigned to observe him had temporarily left his bay and suffered a fatal fall. The report identified staffing shortages as contributing to the incident and raised concern that ongoing shortages at Clifton Hospital were putting elderly and vulnerable patients at risk.
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 Shortage of staff for required patient care tasks
Wider context from the report “However, it was not disputed there are long – standing challenges in terms of staffing levels , notwithstanding efforts that have been and continue to be made in relation to recruitment of new staff.
However, during this inquest the hospital staff could not have been clearer in their views: do to the reduction in staff numbers, they did not have enough time to carry out their expected tasks . As one HCA told the court, it was “impossible” to provide one to one nursing care to Mr Housby with the number of staff working that shift at that time .
The court was told that since Mr Housby’s death, the problem of staffing shortages persists .
My concern therefore is as follows: Clifton hospital is a place where patients – often elderly and vulnerable – are transferred for a period of rehabilitation, usually from an acute hospital setting. The aim usually is that following such rehabilitation they can hopefully return to their homes, or perhaps be discharged to a suitable care home. However, these patients are being put at risk due to a shortage of staff .
” Open source report
Concerns raised 1 Lack of clarity over responsibility for monitoring GP antibiotic prescribing requested by a hospital 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
Ethel Ann Beaumont · 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
Ethel Ann Beaumont died on 11 May 2020 after developing nitrofurantoin-induced liver injury and liver failure while being treated before planned surgery. The report found that a significantly raised ALT result should have been followed up promptly and raised concerns about unclear responsibility between hospital and primary care for monitoring antibiotics prescribed at the hospital’s request.
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 clarity over responsibility for monitoring GP antibiotic prescribing requested by a hospital
Wider context from the report “that there is a lack of clarity between hospital and primary care as to which of them should be responsible for monitoring where a GP is prescribing an antibiotic on the request of the hospital that a patient is attending regularly for review. I am concerned that these pathways should be clarified and that there remains a risk of future death at present.
” Open source report
3 Nov 2021 Angela Margaret O’Donnell · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 2 Shortage of nursing staff View source Reliance on agency nursing staff 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
Angela Margaret O’Donnell · 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
Angela Margaret O’Donnell, who had advanced lung cancer, was admitted to hospital with confusion and pain and died in hospital on 14 January 2020. The report identifies incomplete NEWS charting and missed opportunities to escalate her deteriorating condition, while stating that this was not found to have caused her death. The principal concern was reliance on agency nurses, who may not receive the trust’s refresher training and related communications, in the context of wider nursing staff shortages.
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 Shortage of nursing staff
Wider context from the report “(2) What plans are there nationally to reduce the shortage of nursing staff going forward ? This question is for the Secretary of State.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Reliance on agency nursing staff
Wider context from the report “(1) Is the trust able to carry out any steps to reduce their reliance on agency nursing staff – for instance, by using nurses from a smaller pool of their own bank staff who receive the same training as permanent staff, or any other similar measures? This question is for the hospital trust.
” Open source report
Concerns raised 3 Failure to take wound photographs for continuity and reference View source Lack of continuity in community nursing staff assessing wounds View source Unavailability of electronic records to District Nurses during home visits 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
Jane Lesley Bruce · 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
Jane Bruce sustained a right tibia and fibula fracture after a fall, underwent surgery, and was receiving community wound care when her condition deteriorated. She presented to hospital with features consistent with sepsis and died the following day. The principal concern was that fragmented community nursing care, lack of wound photographs, and inability to access electronic records contributed to her deterioration not being fully appreciated and delayed escalation for medical review.
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 wound photographs for continuity and reference
Wider context from the report “Ms Bruce was care for in the community by several different District Nurses. This meant that it was not the same nurse who was always seeing the wound. No photographs were taken for continuity / reference to and the electronic records could not be accessed by the District Nurses while they were in Ms Bruce’s home. This meant that all information that could have been available was not. This meant that Ms Bruce’s change in condition was not fully appreciated.
Leicestershire Partnership Trust have learned from this and District Nurse now have work mobile phones so that they can take photographic evidence of wounds as well as IT technology that means they can access the electronic records while they are with the patient. In addition, they also have a ‘sepsis’ bag containing equipment to record the blood pressure, oxygen saturation levels and temperature.
Although this lesson has been learned and changes made to prevent future deaths locally, the concern is that the practice that was in place at the time of Ms Bruce’s death may be practice elsewhere.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of continuity in community nursing staff assessing wounds
Wider context from the report “Ms Bruce was care for in the community by several different District Nurses. This meant that it was not the same nurse who was always seeing the wound. No photographs were taken for continuity / reference to and the electronic records could not be accessed by the District Nurses while they were in Ms Bruce’s home. This meant that all information that could have been available was not. This meant that Ms Bruce’s change in condition was not fully appreciated.
Leicestershire Partnership Trust have learned from this and District Nurse now have work mobile phones so that they can take photographic evidence of wounds as well as IT technology that means they can access the electronic records while they are with the patient. In addition, they also have a ‘sepsis’ bag containing equipment to record the blood pressure, oxygen saturation levels and temperature.
Although this lesson has been learned and changes made to prevent future deaths locally, the concern is that the practice that was in place at the time of Ms Bruce’s death may be practice elsewhere.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of electronic records to District Nurses during home visits
Wider context from the report “Ms Bruce was care for in the community by several different District Nurses. This meant that it was not the same nurse who was always seeing the wound. No photographs were taken for continuity / reference to and the electronic records could not be accessed by the District Nurses while they were in Ms Bruce’s home . This meant that all information that could have been available was not. This meant that Ms Bruce’s change in condition was not fully appreciated.
Leicestershire Partnership Trust have learned from this and District Nurse now have work mobile phones so that they can take photographic evidence of wounds as well as IT technology that means they can access the electronic records while they are with the patient. In addition, they also have a ‘sepsis’ bag containing equipment to record the blood pressure, oxygen saturation levels and temperature.
Although this lesson has been learned and changes made to prevent future deaths locally, the concern is that the practice that was in place at the time of Ms Bruce’s death may be practice elsewhere.
” Open source report
23 Oct 2021 Margaret Kinsey · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Lack of on-site emergency department consultant cover from late evening until morning View source Insufficient senior emergency department doctor staffing at night View source Lack of a standard approach for documenting and signing off supervisory clinical discussions View source Failure to provide adequate night-time supervision and support for junior emergency department doctors View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Margaret Kinsey · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Margaret Rose Kinsey, who had significant heart disease, was discharged from Stepping Hill Hospital Emergency Department on 11 December 2020 after presenting with shortness of breath and significant bilateral leg swelling. She collapsed at home the following day and died after attempts to resuscitate her were unsuccessful; post mortem examination found acute left ventricular failure caused by her underlying heart disease. The substantive concerns included limited overnight consultant cover, difficulties supervising an inexperienced junior doctor, and inconsistent documentation of clinical discussions and supervision.
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 on-site emergency department consultant cover from late evening until morning
Wider context from the report “2. The inquest heard that there was a shortage of ED consultants across the NHS which led to these challenges in relation to staffing ED and that it was not uncommon for staffing of ED to be based on there being no on site consultant cover in ED from late evening until the morning .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 senior emergency department doctor staffing at night
Wider context from the report “1. The inquest heard that due to the time of her arrival in the Emergency Department on 11th December 2020 consultants were not on site . The most senior doctors available were middle grade and the number available at that time of night was significantly reduced . As a consequence the evidence was that supervision and support of junior doctors was very difficult given the demands on the middle grade doctors on site. This was exacerbated by the fact that on the evening Mrs Kinsey was admitted the FY doctors had just rotated. The FY2 who saw her had very limited post qualification experience of Emergency Medicine. The inquest heard that particularly at night time support and supervision of FY ED doctors presents significant challenges across the NHS in relation to patient care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a standard approach for documenting and signing off supervisory clinical discussions
Wider context from the report “3. The inquest heard that there was no standard approach as to how the details of information shared/discussions between clinicians should be detailed or signed off in the notes when one clinician was acting in a supervisory capacity . Given the regular movement of junior doctors across the NHS this meant documentation quality was inconsistent .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate night-time supervision and support for junior emergency department doctors
Wider context from the report “1. The inquest heard that due to the time of her arrival in the Emergency Department on 11th December 2020 consultants were not on site. The most senior doctors available were middle grade and the number available at that time of night was significantly reduced. As a consequence the evidence was that supervision and support of junior doctors was very difficult given the demands on the middle grade doctors on site . This was exacerbated by the fact that on the evening Mrs Kinsey was admitted the FY doctors had just rotated. The FY2 who saw her had very limited post qualification experience of Emergency Medicine. The inquest heard that particularly at night time support and supervision of FY ED doctors presents significant challenges across the NHS in relation to patient care .
” Open source report
22 Oct 2021 Serena Naomi Roberts · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Poor documentation in GP referrals to secondary care View source Lack of GP referral follow-up systems to identify increased patient risk View source Delays in secondary-care appointments for gynaecological referrals View source Failure of GP referral follow-up systems to escalate referrals when required View source Lack of GP referral follow-up systems to identify referrals that have not taken place View source Failure in General Practice to understand and apply guidance on heavy premenstrual bleeding and expedite specialist referral View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Serena Naomi Roberts · 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
Serena Naomi Roberts experienced recurrent very heavy vaginal bleeding and delays in referral, triage and follow-up for specialist gynaecological assessment. She was later found to have ovarian cancer with extensive peritonitis and died from complications including septic shock and intra-abdominal sepsis. The principal concerns included delays in secondary care, poor recognition and application of guidance on heavy bleeding and risk factors, inadequate referral information, and a lack of clear systems to follow up referrals.
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 Poor documentation in GP referrals to secondary care
Wider context from the report “3. The quality of the documentation in the referral to secondary care form the GP was poor and the inquest was told that this hampered the triage of her case by secondary care . Standardisation of GPs referrals in relation to detail and guidance regarding key information for referral would assist with effective triage and identification of high risk patients by secondary care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of GP referral follow-up systems to identify increased patient risk
Wider context from the report “4. There was no evidence available that GP practices had clear systems of follow up in relation to referrals to identify where they had not taken place or identify if the risk had increased and to escalate the referral.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 secondary-care appointments for gynaecological referrals
Wider context from the report “1. The inquest heard that there were significant delays in patients being seen in secondary care for gynaecological referrals from GPs . The inquest was told that these delays had now increased . In November 2020 the wait time for an appointment was 1 month for an urgent appointment and 4 months for a routine appointment. The wait times now in Tameside for gynaeocology were 8 months for a routine appointment and 4 months for urgent appointments. The increase in wait times reflected a national picture the inquest was told and reflected a significant backlog and a rising demand 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 Failure of GP referral follow-up systems to escalate referrals when required
Wider context from the report “4. There was no evidence available that GP practices had clear systems of follow up in relation to referrals to identify where they had not taken place or identify if the risk had increased and to escalate the referral .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 GP referral follow-up systems to identify referrals that have not taken place
Wider context from the report “4. There was no evidence available that GP practices had clear systems of follow up in relation to referrals to identify where they had not taken place or identify if the risk had increased and to escalate the referral.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 in General Practice to understand and apply guidance on heavy premenstrual bleeding and expedite specialist referral
Wider context from the report “2. The inquest heard that understanding and application of the NICE guidance on heavy premenstrual bleeding in General Practice was a factor in recognising the risk to her health and that the risks around heavy premenstrual bleeding were not well understood in General Practice and in particular where it was necessary to expedite referral to specialist services .
” Open source report
22 Oct 2021 Anthony John Larcher · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 5 Failure of SystmOne to make vital prison healthcare information readily identifiable View source Failure to identify prisoners’ health information during large-cohort reception View source Lack of observations and welfare checks for prisoners found under the influence of psychoactive substances View source Lack of healthcare staff attendance at ACCT reviews View source Lack of 24-hour healthcare across the prison estate View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anthony John Larcher · 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 21 March 2018, Anthony John Larcher, a serving prisoner at HMP Guys Marsh, was found in his cell. The report identifies concerns about monitoring prisoners under the influence of psychoactive substances, the lack of round-the-clock healthcare, healthcare involvement in ACCT reviews, the accessibility of medical information, and the reception of prisoners arriving in large cohorts.
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 SystmOne to make vital prison healthcare information readily identifiable
Wider context from the report “iv. I am concerned that vital information contained within a prisoner’s medical health records stored on SystmOne, could be missed due to fact the software is more adapted to GP practice than prison healthcare . This could result in a future death and I request consideration is given to adapting SystmOne for better use in prisons to ensure information, especially where there are complex care needs, is easily assessable and highlighted to avoid crucial information regarding a patient’s care and safety being missed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to identify prisoners’ health information during large-cohort reception
Wider context from the report “v. I have concerns with the movement of prisoners around the prison estate in large cohorts as it could result in information regarding a prisoner’s health not being identified which could result in a lack of healthcare provision to the prisoner which could result in a future death. I therefore request that consideration be given to the review of the processes when large cohorts are received at prisons and the resources available to prison and healthcare staff prior to the arrival of the prisoner and during the progression of the prisoners through the reception process.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 observations and welfare checks for prisoners found under the influence of psychoactive substances
Wider context from the report “i. There could be future deaths across the prison estate nationally due to a lack of observations and welfare checks upon prisoners who are found under the influence of Spice and I request consideration be given to the rolling out of the local processes adopted at HMP Guys Marsh, nationally. This includes the roll out of their Welfare Checks Policy, the Persistent Psychoactive Substances Intervention Plan (PPSIP) and the Custodial Officer Intermediate Life Support initiative (COILS).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 healthcare staff attendance at ACCT reviews
Wider context from the report “iii. I have concerns that future deaths could occur due to the lack of attendance of healthcare staff at ACCT reviews, especially where the ACCT is closed . I request that consideration is given to providing guidance nationally by way of a safety bulletin or an update to the ACCT version 6 guidance and in the new PSI to be released in the future on the policy on management of prisoners at risk of harm to self, to others and from others, ensuring the attendance of healthcare staff at all ACCT reviews.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 24-hour healthcare across the prison estate
Wider context from the report “ii. I have concerns that future deaths could occur due to the lack of 24 hour healthcare across the prison estate . I would therefore request consideration be given to the provision of healthcare to all prisons 24 hours a day, 7 days a week.
” 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 Healthcare matters in the prison estate are commissioned by NHS England and Improvement, which has already provided a response.
Verbatim wording from the response “NHS England and NHS Improvement (NHSEI) is responsible for the commissioning of healthcare for the prison estate. I am aware that NHSEI has provided a response to you on the matters of concern in your report relating to healthcare. I will not repeat the detail of that response. However, I offer the following comments.” Source location 2021-0356-Response-from-Department-of-Health-Social-Care_Published
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 Responsibility for the Assessment, Care in Custody and Teamwork process lies with HMPPS, which will respond on that matter.
Verbatim wording from the response “In relation to healthcare participation in the Assessment, Care in Custody and Teamwork (ACCT) process, and in particular, the consideration of closing an ACCT, I am advised that NHSEI has worked with HMPPS to review the ACCT process and healthcare attendance and findings are anticipated in early 2022. Responsibility for the ACCT process lies with HMPPS and I am informed that it will respond to you fully on this matter.” Source location 2021-0356-Response-from-Department-of-Health-Social-Care_Published
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