10 Mar 2026 Sheila Creagan · Prevention of Future Deaths report East London
View report summary
Concerns raised 5 Failure to investigate deaths under the Patient Safety Framework View source Failure to accurately determine and record the cause of death View source Failure to diagnose infective endocarditis View source Failure to monitor developing heart failure during inpatient treatment View source Failure to investigate the source of a progressing infection after pneumonia resolves View source See 2 more concerns
Responses linked to these concerns
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AI-generated summary
Sheila Creagan · 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
Sheila Creagan, an 81-year-old woman with heart failure, underwent emergency abdominal surgery in February 2025 and was later admitted with breathing difficulties, anaemia and a suspected gastrointestinal bleed. She died in hospital on 17 March 2025; the inquest determined that untreated and undiagnosed infective endocarditis caused her death. Concerns included the failure to investigate the source of her worsening infection, the missed diagnosis of infective endocarditis, inadequate monitoring of her heart failure, and the decision not to conduct a Patient Safety Framework investigation.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate deaths under the Patient Safety Framework
Wider context from the report “1. BHRUT chose not to investigate this case as part of NHS England’s Patient Safety Framework . Mrs Creagan’s death ought to have been subject to such an investigation .
Decisions were reached at two clinical governance meetings that meaningful learning could not flow from a governance investigation into the circumstances of Mrs Creagan’s care . Such decisions appear to be incongruous with;
a. The inaccurate cause of death initially offered by the Trust,
b. The failure to investigate the seat of Mrs Creagan’s burgeoning infection after her pneumonia resolved.
c. The missed diagnosis of infective endocarditis,
d. The failure to monitor the development of Mrs Creagan’s heart failure during her inpatient treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately determine and record the cause of death
Wider context from the report “1. BHRUT chose not to investigate this case as part of NHS England’s Patient Safety Framework. Mrs Creagan’s death ought to have been subject to such an investigation.
Decisions were reached at two clinical governance meetings that meaningful learning could not flow from a governance investigation into the circumstances of Mrs Creagan’s care. Such decisions appear to be incongruous with;
a. The inaccurate cause of death initially offered by the Trust ,
b. The failure to investigate the seat of Mrs Creagan’s burgeoning infection after her pneumonia resolved.
c. The missed diagnosis of infective endocarditis,
d. The failure to monitor the development of Mrs Creagan’s heart failure during her inpatient treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to diagnose infective endocarditis
Wider context from the report “1. BHRUT chose not to investigate this case as part of NHS England’s Patient Safety Framework. Mrs Creagan’s death ought to have been subject to such an investigation.
Decisions were reached at two clinical governance meetings that meaningful learning could not flow from a governance investigation into the circumstances of Mrs Creagan’s care. Such decisions appear to be incongruous with;
a. The inaccurate cause of death initially offered by the Trust,
b. The failure to investigate the seat of Mrs Creagan’s burgeoning infection after her pneumonia resolved.
c. The missed diagnosis of infective endocarditis ,
d. The failure to monitor the development of Mrs Creagan’s heart failure during her inpatient treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor developing heart failure during inpatient treatment
Wider context from the report “1. BHRUT chose not to investigate this case as part of NHS England’s Patient Safety Framework. Mrs Creagan’s death ought to have been subject to such an investigation.
Decisions were reached at two clinical governance meetings that meaningful learning could not flow from a governance investigation into the circumstances of Mrs Creagan’s care. Such decisions appear to be incongruous with;
a. The inaccurate cause of death initially offered by the Trust,
b. The failure to investigate the seat of Mrs Creagan’s burgeoning infection after her pneumonia resolved.
c. The missed diagnosis of infective endocarditis,
d. The failure to monitor the development of Mrs Creagan’s heart failure during her inpatient treatment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate the source of a progressing infection after pneumonia resolves
Wider context from the report “1. BHRUT chose not to investigate this case as part of NHS England’s Patient Safety Framework. Mrs Creagan’s death ought to have been subject to such an investigation.
Decisions were reached at two clinical governance meetings that meaningful learning could not flow from a governance investigation into the circumstances of Mrs Creagan’s care. Such decisions appear to be incongruous with;
a. The inaccurate cause of death initially offered by the Trust,
b. The failure to investigate the seat of Mrs Creagan’s burgeoning infection after her pneumonia resolved .
c. The missed diagnosis of infective endocarditis,
d. The failure to monitor the development of Mrs Creagan’s heart failure during her inpatient treatment.
” 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 BHRUT is responsible for responding to the broader concerns raised about Mrs Creegan’s care and the application of PSIRF.
Verbatim wording from the response “In preparing this response, my officials have made enquiries with NHS England and the Care Quality Commission (CQC) to ensure we adequately address your concerns on PSIRF. I note you have also copied your report to Barking, Havering, and Redbridge University Hospitals NHS Trust (BHRUT) who will respond to the broader concerns you have raised.” Source location Response from Department of Health and Social Care
Open published response
5 Mar 2026 Joanna HILLARD · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 2 Failure of capacity law to recognise the effects of coercive and controlling behaviour on decision-making ability View source Lack of understanding of the effects of controlling and coercive behaviour on decision-making capacity 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
Joanna HILLARD · 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
Joanna Hillard was discovered at her home on 25 February 2021 and could not be revived despite CPR. The inquest concluded that her death was suicide contributed to by coercive and controlling behaviour. The principal concern was that the effects of coercive and controlling behaviour on a person's decision-making ability may not be adequately recognised under the Mental Capacity Act 2005 and current capacity law.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of capacity law to recognise the effects of coercive and controlling behaviour on decision-making ability
Wider context from the report “I am concerned that there is a lack of understanding of the effects of controlling and coercive behaviour on a person’s ability to make a decision in their best interests. I am concerned that people who live in a level of fear (resultant from coercive and controlling behaviour) may have their decision-making abilities negatively affected and the law surrounding capacity, as currently drafted, does not recognise this .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the effects of controlling and coercive behaviour on decision-making capacity
Wider context from the report “I am concerned that there is a lack of understanding of the effects of controlling and coercive behaviour on a person’s ability to make a decision in their best interests . I am concerned that people who live in a level of fear (resultant from coercive and controlling behaviour) may have their decision-making abilities negatively affected and the law surrounding capacity, as currently drafted, does not recognise this.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The MCA need not override unsafe or unwise decisions where capacity exists because safeguarding, civil and criminal routes are available.
Verbatim wording from the response “Although section 76 Serious Crime Act 2015 offence post-dates the MCA, it was developed and updated alongside the modern adult safeguarding framework (including the Care Act 2014 and the Domestic Abuse Act 2021) and is supported by statutory guidance: Controlling or coercive behaviour: statutory guidance framework - GOV.UK. The MCA remains relevant where coercion or undue influence interacts with an impairment or disturbance of the mind or brain so that the person cannot make the specific decision, in such cases, practitioners should complete and record a decision-specific capacity assessment. Where an adult has capacity, the MCA is not a general route to override unsafe or unwise decisions, and other safeguarding, civil and criminal routes may be more appropriate.” Source location 2026-0128 - Response from Department of Health and Social Care
Open published response
4 Mar 2026 Roman Louie BARR · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 6 Risk to critically unwell patients and families when families transport patients to hospital during time-critical emergencies View source Delays in ambulance handover reducing emergency ambulance availability View source Failure to reliably identify excessive or repeated requests for salbutamol inhalers View source Lack of a consistent follow-up process for salbutamol overuse patterns View source Limited awareness of the significance of salbutamol overuse in patients and families View source Failure of NHS Pathways triage wording to be readily understood by callers in distress View source See 3 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
Roman Louie BARR · 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
Roman Louie Barr suffered an asthma attack on 14 December 2023 and died after no ambulance was available for several hours, leading his family to transport him to hospital. The principal concerns were limited awareness and follow-up of excessive salbutamol use, ambulance handover delays affecting emergency availability, risks to families transporting critically unwell patients, and unclear NHS Pathways triage wording.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Risk to critically unwell patients and families when families transport patients to hospital during time-critical emergencies
Wider context from the report “4. Risks when families transport critically unwell patients
The absence of an available ambulance for several hours resulted in the family transporting Roman to hospital themselves, exposing both him and his family to significant risk during a time-critical medical emergency .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover reducing emergency ambulance availability
Wider context from the report “3. Ambulance handover delays affecting emergency availability
Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought , reducing emergency response capacity during periods of high demand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 reliably identify excessive or repeated requests for salbutamol inhalers
Wider context from the report “2. Identification and follow-up of reliever overuse
Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems , and there may be no consistent process for follow-up when such patterns occur, meaning deteriorating asthma may go unrecognised.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 consistent follow-up process for salbutamol overuse patterns
Wider context from the report “2. Identification and follow-up of reliever overuse
Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems, and there may be no consistent process for follow-up when such patterns occur , meaning deteriorating asthma may go unrecognised.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 awareness of the significance of salbutamol overuse in patients and families
Wider context from the report “1. Limited awareness of salbutamol overuse
Evidence showed that patients and families may not appreciate the clinical significance of increased use of the blue (salbutamol) inhaler or its association with poorly controlled asthma .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 NHS Pathways triage wording to be readily understood by callers in distress
Wider context from the report “5. Clarity of NHS Pathways triage wording
Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information . This raises a concern that, given the reliance on scripted triage systems, such scripts may not always use wording that is easily understood by lay callers in distress .
” 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 Fund urgent and emergency care capacity expansions, connected ambulance care records, and replacement ambulances.
Verbatim wording from the response “Over £450m of capital investment last year supported expansions to urgent and emergency care capacity, including new and expanded Same Day Emergency Care (SDEC) and Urgent Treatment Centres (UTCs), connected care records for ambulance services, and nearly” 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 Engage health system partners to coordinate resources and implementation of NICE asthma guidance on appropriate inhaler treatment and use.
Verbatim wording from the response “On the concerns you raised on monitoring of reliever overuse, to support implementation of NICE’s guidance "Asthma: diagnosis, monitoring and chronic asthma management", published November 27, 2024, NHS England has been engaging with health system partners to coordinate resources and implementation efforts to make sure that patients are on the appropriate treatment regimen and are using their inhaler (preventer or reliever) at the right time, with the right technique. The over-prescribing of reliever inhalers amongst people with asthma has seen a steady fall over the past few years.” 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 Implement the Release to Rescue approach across trusts, beginning handover at 30 minutes and completing it by 45 minutes.
Verbatim wording from the response “To ensure timely patient care and release ambulances back into the community, the plan mandated the “Release to Rescue” approach which will be continually implemented across all trusts. This requires the handover process to begin at 30 minutes and be completed by 45 minutes. There is significant progress still to be made on this commitment, the most recent performance figures show that average handover time in the West Midlands Ambulance Service was 54 minutes and 30 seconds. NHSE continues to work with the most challenged trusts, with the Medium-term Planning Framework (2026/27–2028/29) setting further ambitions for acute and ambulance collaboration to further improve performance, including progress toward the 15-minute handover standard and reducing pressure in hospitals.” 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 Review ambulance triage outcome mapping and evidence, recommending changes to triage questions for implementation across providers.
Verbatim wording from the response “Within NHS England, the mapping of triage outcomes to response categories is undertaken and reviewed regularly by an expert group which makes recommendations to the NHS England Emergency Call Prioritisation Advisory Group (ECPAG) for implementation across all NHS ambulance service providers.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England will address the report’s other concerns in a separate response.
Verbatim wording from the response “The report raises concerns over the continued pressure caused by prolonged ambulance handover times at local hospitals which reduced emergency capacity to respond in the community, risk of patient’s family transporting Roman to hospital themselves and clarity of NHS Pathways triage wording. NHS England will reply separately on other concerns in your report.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Nationally approved triage systems, clinical support, oversight and regular script review provide the framework for consistent, safe 999 call handling.
Verbatim wording from the response “NHS Ambulance Services in England must process 999 calls through a nationally approved clinical triage system. NHS England currently approves two systems in England for primary 999 assessments: NHS Pathways and Medical Priority Dispatch System (MPDS). This ensures that there is a degree of consistency and standardisation in 999 call handling.” Source location Response from Department of Health and Social Care
Open published response
4 Mar 2026 Roman Louie BARR · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 6 Limited awareness of salbutamol overuse and its association with poorly controlled asthma View source Delays in ambulance handover at local hospitals View source Failure to reliably identify excessive or repeated requests for salbutamol inhalers View source Failure of NHS Pathways triage wording to be readily understood by callers in distress View source Risk to critically unwell patients and families when no ambulance is available and families transport patients themselves View source Lack of a consistent follow-up process for salbutamol overuse patterns 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
Roman Louie BARR · 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
Roman Louie Barr suffered an asthma attack on 14 December 2023 and died after information indicating the need for an urgent ambulance response was not obtained, no ambulance was available for several hours, and his family transported him to hospital. The principal concerns included limited awareness and monitoring of excessive salbutamol use, ambulance handover delays affecting emergency availability, risks when families transport critically unwell patients, and unclear NHS Pathways triage wording.
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 Limited awareness of salbutamol overuse and its association with poorly controlled asthma
Wider context from the report “1. Limited awareness of salbutamol overuse
Evidence showed that patients and families may not appreciate the clinical significance of increased use of the blue (salbutamol) inhaler or its association with poorly controlled asthma .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover at local hospitals
Wider context from the report “3. Ambulance handover delays affecting emergency availability
Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 reliably identify excessive or repeated requests for salbutamol inhalers
Wider context from the report “2. Identification and follow-up of reliever overuse
Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems , and there may be no consistent process for follow-up when such patterns occur, meaning deteriorating asthma may go unrecognised.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 NHS Pathways triage wording to be readily understood by callers in distress
Wider context from the report “5. Clarity of NHS Pathways triage wording
Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information . This raises a concern that, given the reliance on scripted triage systems, such scripts may not always use wording that is easily understood by lay callers in distress .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Risk to critically unwell patients and families when no ambulance is available and families transport patients themselves
Wider context from the report “4. Risks when families transport critically unwell patients
The absence of an available ambulance for several hours resulted in the family transporting Roman to hospital themselves, exposing both him and his family to significant risk during a time-critical medical emergency .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 consistent follow-up process for salbutamol overuse patterns
Wider context from the report “2. Identification and follow-up of reliever overuse
Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems, and there may be no consistent process for follow-up when such patterns occur , meaning deteriorating asthma may go unrecognised.
” Open source report
27 Feb 2026 Maisie Kate Almond · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Delayed availability of suitable donor livers for children in the “super urgent” category View source National shortage of suitable donor livers for children in the “super urgent” category 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
Maisie Kate Almond · 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
Maisie Kate Almond, aged 14, developed acute liver failure in September 2024 and died on 2 October 2024 after cerebral oedema and multi-organ failure developed while she was awaiting an urgent liver transplant. The report identifies a national shortage of donor livers, particularly for children in the “super urgent” category, with waiting times extending from historically around 48 hours to up to a week. It states that this delay creates a clear risk that lives will be lost because suitable donor organs are unavailable.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delayed availability of suitable donor livers for children in the “super urgent” category
Wider context from the report “During the inquest, I heard evidence from a consultant paediatric hepatologist that there is a national shortage of donor livers generally and particularly for children in the “super urgent” category.
The clinical guidance not to utilise cardiac death donor livers in such cases due to the poor historical outcomes has narrowed the pool of suitable donor livers to those arising from brain deaths. Altruistic living liver donations are generally not available for super urgent cases.
The evidence I received was that the number of donor livers has reduced by a third and the effect is that whereas, historically, a donor liver could be expected to be made available within 48 hours, the wait has now extended to up to a week .
That delay gives rise to a clear risk that lives will be lost due to the unavailability of suitable donor organs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation National shortage of suitable donor livers for children in the “super urgent” category
Wider context from the report “During the inquest, I heard evidence from a consultant paediatric hepatologist that there is a national shortage of donor livers generally and particularly for children in the “super urgent” category .
The clinical guidance not to utilise cardiac death donor livers in such cases due to the poor historical outcomes has narrowed the pool of suitable donor livers to those arising from brain deaths. Altruistic living liver donations are generally not available for super urgent cases.
The evidence I received was that the number of donor livers has reduced by a third and the effect is that whereas, historically, a donor liver could be expected to be made available within 48 hours, the wait has now extended to up to a week.
That delay gives rise to a clear risk that lives will be lost due to the unavailability of suitable donor organs .
” 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 Develop the Assessment and Recovery Centre programme as a national multi-organ approach, with phased lung, liver and kidney pilots during 2026.
Verbatim wording from the response “with the aim of improving organ utilisation, reducing unwarranted variation and supporting more transplants to occur.” Source location Response from Department of Health & 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 the Organ Donation Joint Working Group and publish its ten actions for improving deceased organ donation.
Verbatim wording from the response “Organ Donation Joint Working Group (ODJWG)” Source location Response from Department of Health & Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide funding for the development and mobilisation of Assessment and Recovery Centre pilot schemes.
Verbatim wording from the response “Assessment and Recovery Centres” Source location Response from Department of Health & Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clinicians, rather than the Department, decide whether organs including DCD livers are clinically suitable for transplantation.
Verbatim wording from the response “The Department recognises the concerns raised in your report about the impact that limitations on suitable donor liver availability can have on children requiring super urgent transplantation. Decisions regarding the clinical suitability of organs for transplantation, including the use of DCD livers, are made by clinicians and are based on the best available evidence. NHSBT has advised that, while DCD livers are an important source of organs when transplanted as whole livers, they are not routinely split, which is often required for paediatric cases. This is because splitting DCD livers is associated with a higher risk of graft failure and poorer outcomes for recipients.” Source location Response from Department of Health & Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current evidence-based guidance limiting routine splitting of DCD livers is kept under regular review and will change only when robust evidence supports safe improvement.
Verbatim wording from the response “The Department recognises the concerns raised in your report about the impact that limitations on suitable donor liver availability can have on children requiring super urgent transplantation. Decisions regarding the clinical suitability of organs for transplantation, including the use of DCD livers, are made by clinicians and are based on the best available evidence. NHSBT has advised that, while DCD livers are an important source of organs when transplanted as whole livers, they are not routinely split, which is often required for paediatric cases. This is because splitting DCD livers is associated with a higher risk of graft failure and poorer outcomes for recipients.” Source location Response from Department of Health & Social Care
Open published response
27 Feb 2026 SUMMER RAE MANT · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Lack of standardised crash trolleys across hospital settings 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
SUMMER RAE MANT · 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
Summer Rae Mant, a four-year-old child with MIRAGE syndrome, developed severe infection and virus while an inpatient and suffered hypoxia and cardiac arrest during events on 17 and 18 March 2024. She later developed sudden multi-organ failure of uncertain cause and died at Ty Hafan on 21 September 2024. A substantive concern was a delay in obtaining adrenaline during resuscitation, associated with non-standardised crash trolleys and staff unfamiliarity with different hospital configurations.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of standardised crash trolleys across hospital settings
Wider context from the report “During the resuscitation of Summer at Prince Charles Hospital in the theatre following intubation, there was a delay in obtaining adrenaline. The incident occurred at night and it involved a skeleton staff including some junior doctors, fairly new to the hospital.
The delay in finding adrenaline, was likely due to the fact that there is no standardised crash trolley , and junior doctors frequently rotate between hospitals and health boards and encounter different set-ups .
Paediatric crash trolleys are necessarily different to adult crash trolleys, but there was consensus in evidence that it would be safer if there was a single standardised version of each type across every hospital setting in which junior doctors rotate , to minimise confusion at a time critical moment.
” Open source report
26 Feb 2026 Urmila Patel · Prevention of Future Deaths report East London
View report summary
Concerns raised 9 Failure to make decisive urgent CT head scan referrals View source Failure to review preceding clinical records for relevant falls information View source Failure to undertake adequate falls risk assessments View source Failure to adequately assess the likelihood of traumatic intracranial bleeding after a fall View source Failure to record falls View source Failure to monitor and supervise patients View source Failure to produce meaningful mobility care plans View source Failure to reassess falls risk after a fall View source Failure to review warfarin prescriptions after a fall View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Urmila Patel · 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
Urmila Patel, aged 78, was admitted to hospital with suspected sepsis and later fell in a ward toilet on 29 June 2025. She subsequently deteriorated and died in hospital on 7 July 2025 after a CT scan identified a significant subdural haematoma. The concerns included inadequate falls-risk assessment, mobility care planning, supervision, assessment for intracranial bleeding, timely CT referral, and review of her warfarin after the fall.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to make decisive urgent CT head scan referrals
Wider context from the report “1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel.
2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility.
3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls.
4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025.
5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025.
6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025.
7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall.
8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to review preceding clinical records for relevant falls information
Wider context from the report “1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel.
2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility.
3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls.
4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025.
5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025.
6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025.
7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall.
8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake adequate falls risk assessments
Wider context from the report “1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel.
2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility.
3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls.
4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025.
5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025.
6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025.
7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall.
8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 adequately assess the likelihood of traumatic intracranial bleeding after a fall
Wider context from the report “1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel.
2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility.
3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls.
4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025.
5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025.
6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025.
7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall.
8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 falls
Wider context from the report “1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel.
2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility.
3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls.
4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025.
5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025.
6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025.
7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall.
8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 monitor and supervise patients
Wider context from the report “1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel.
2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility.
3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls.
4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025.
5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025.
6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025.
7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall.
8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 produce meaningful mobility care plans
Wider context from the report “1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel.
2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility .
3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls.
4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025.
5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025.
6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025.
7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall.
8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 reassess falls risk after a fall
Wider context from the report “1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel.
2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility.
3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls .
4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025.
5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025.
6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025.
7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall.
8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to review warfarin prescriptions after a fall
Wider context from the report “1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel.
2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility.
3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls.
4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025.
5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025.
6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025.
7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall .
8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025.
” 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 NHS England, which oversees the issues raised, is responsible for responding directly to the Prevention of Future Deaths report.
Verbatim wording from the response “Given the concerns you have raised I feel it is important that you receive a response directly from NHS England as it has oversight for the issues you raise. Therefore, my officials have contacted NHS England who have agreed to respond to you directly about the Prevention of Future Death report concerning Mrs Patel.” Source location Response from Department of Health and Social Care
Open published response
19 Feb 2026 Jane Ann FENWICK · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 3 Failure to refer people at risk of choking to Speech and Language Therapy for support and intervention View source Delays in access to Speech and Language Therapy support View source Failure to supervise people while eating in accordance with care plans View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jane Ann FENWICK · 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 Ann Fenwick died on 21 August 2025 at Kettering General Hospital after choking on a piece of beef at her care home. She had no teeth, did not wear dentures, tended to rush and overfill her mouth, preferred softer food, and had a care plan identifying a choking risk. The principal concerns were the threshold for Speech and Language Therapy intervention and support, and the waiting time for that support, despite her identified risks and lack of supervision while eating.
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 refer people at risk of choking to Speech and Language Therapy for support and intervention
Wider context from the report “Mrs Fenwick:-
a) had no teeth
b) did not wear her dentures
c) had a tendency to rush her food
d) had a tendency to put too much in her mouth
e) had poor posture and generally did not sit at a table to eat
f) did not sit still
g) was generally not supervised whilst eating (despite the care plan recommending she be observed while eating)
h) had a preference for softer food
i) had a care plan which identified a risk of choking
Despite the above, Mrs Fenwick had not been referred to Speech and Language Therapy (SALT). The care home’s evidence was that even if Mrs Fenwick had been referred to SALT, she would not have met their threshold for support and intervention on the basis that there had been no previous episodes of choking .
The care home also said in evidence that the average wait for SALT support is 13 weeks.
I have concerns regarding the threshold for intervention/support and the current waiting lists.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Speech and Language Therapy support
Wider context from the report “Mrs Fenwick:-
a) had no teeth
b) did not wear her dentures
c) had a tendency to rush her food
d) had a tendency to put too much in her mouth
e) had poor posture and generally did not sit at a table to eat
f) did not sit still
g) was generally not supervised whilst eating (despite the care plan recommending she be observed while eating)
h) had a preference for softer food
i) had a care plan which identified a risk of choking
Despite the above, Mrs Fenwick had not been referred to Speech and Language Therapy (SALT). The care home’s evidence was that even if Mrs Fenwick had been referred to SALT, she would not have met their threshold for support and intervention on the basis that there had been no previous episodes of choking.
The care home also said in evidence that the average wait for SALT support is 13 weeks.
I have concerns regarding the threshold for intervention/support and the current waiting lists.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 supervise people while eating in accordance with care plans
Wider context from the report “Mrs Fenwick:-
a) had no teeth
b) did not wear her dentures
c) had a tendency to rush her food
d) had a tendency to put too much in her mouth
e) had poor posture and generally did not sit at a table to eat
f) did not sit still
g) was generally not supervised whilst eating (despite the care plan recommending she be observed while eating)
h) had a preference for softer food
i) had a care plan which identified a risk of choking
Despite the above, Mrs Fenwick had not been referred to Speech and Language Therapy (SALT). The care home’s evidence was that even if Mrs Fenwick had been referred to SALT, she would not have met their threshold for support and intervention on the basis that there had been no previous episodes of choking.
The care home also said in evidence that the average wait for SALT support is 13 weeks.
I have concerns regarding the threshold for intervention/support and the current waiting lists.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fund eligible adult social care staff to undertake nutrition, hydration, choking prevention and response training through the Learning and Development Support Scheme.
Verbatim wording from the response “Any form of neglect is unacceptable, and my department recognises the importance of safe, person-centred care, particularly in relation to eating and drinking. This is why the Adult Social Care Learning and Development Support Scheme (LDSS), was launched in September 2024, and provides funding for eligible care staff to undertake courses and qualifications, including the Level 2 Certificate in Understanding Nutrition and Health and relevant content in the Level 2 Adult Social Care Certificate (L2ASCC).” Source location 2026-0104 - Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for reporting separately on current Speech and Language Therapy waiting lists.
Verbatim wording from the response “In preparing this response to your first concern, departmental officials have made enquiries with Care Quality Commission (CQC) and North Northamptonshire Council (NNC) and Chair of the Northamptonshire Safeguarding Adults Board (NSAB). Officials did this to gain a greater insight into any specific reasons for Mrs Fenwick not being referred to SALT and what, if any, follow up actions may have resulted from this case. However, with regards to the second concern, then NHS England, who also received a copy of this report, will be reporting separately on current waiting lists for SALT.” Source location 2026-0104 - Response from Department of Health and Social Care
Open published response
10 Feb 2026 Barbara Wingate · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 1 Failure to provide timely appropriate community care packages or alternative placements for medically fit 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
Barbara Wingate · 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
Barbara Wingate, a 71-year-old woman, fell at home on 18 May 2025, sustained multiple pelvic fractures, suffered a cardiac arrest and died on 21 May 2025 following multiple organ failure. The inquest identified avoidable delays in diagnosing and treating her pelvic fractures. The report also raised concerns about emergency department capacity, delayed discharge of medically fit patients, and insufficient timely community care or alternative placements, creating risks for other critically ill patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely appropriate community care packages or alternative placements for medically fit patients
Wider context from the report “Evidence heard at the inquest revealed that the resuscitation department where Mrs Wingate should have been admitted was full and the evidence indicated that this was and is almost a daily occurrence at the Trust . The court heard that the main issue is trying to discharge a patient to a suitable area in the hospital to free up a cubicle or bay in the resuscitation department. This in turn is due to beds being occupied by patients who are medically fit to be discharged . On any given day the court heard that up to a third of the hospital beds can be filled with patients who are fit to leave hospital.
The court heard that the main delay is in discharging patients to appropriate settings or placements and the Trust have taken all steps they can internally to improve the flow of patients through the hospital. From the evidence it would appear that those responsible for providing care in the community including both the social care providers and the community healthcare providers are not providing either timely appropriate care packages in the patient's home or a bed in an alternative placement be that a nursing home or residential home placement . The evidence suggested that where patients were self funding the delays in discharge were less acute.
This means patients are kept in hospital for longer and thus are more at risk of contracting hospital acquired illnesses themselves which could lead to their own death but are also blocking beds which are needed to treat patients who require acute care . This is leading to patients being kept longer in the emergency department and reducing available space to receive new critically ill patients . Both of these options can lead to death as seen in this case and there is clearly a risk of death for others requiring clinical care in an acute hospital.
” Open source report
10 Feb 2026 Samuel John DICKINSON · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Failure to require General Practitioner practices to record firearms licence holdings in medical records View source Failure to require General Practitioner practices to report relevant health issues to firearms licence units View source Lack of a self-reporting requirement for firearms certificate holders to report relevant illness or mental health conditions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samuel John DICKINSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Samuel John DICKINSON, a 39-year-old farmer who held firearms and shotgun licences, was found on 15 September 2025 with a shotgun wound to the head in an outbuilding at the farm where he lived. The inquest concluded that his death was suicide, with the medical cause recorded as severe head injury. Concerns were raised about gaps in firearms legislation and General Practitioner recording and reporting obligations relating to licence holders’ illnesses or mental health conditions.
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 require General Practitioner practices to record firearms licence holdings in medical records
Wider context from the report “1. During the course of evidence it was reflected that Firearms Legislation relating to the holding of a shotgun or firearms licence (or both) contains no provision that a person holding a certificate must self report any illness or mental health condition which may give rise to a change in circumstances from the time when a grant of licence has been made, differing from obligations for example on a person holding a driving licence to do so.
2. Further it was stated that there is no obligation or provision requiring a General Practitioner practice to:
a. Clearly record the holding of a licence on medical records when advised of the grant, in order to assist with flagging any relevant issues that may need reporting (such as conditions listed on an initial firearms/shotgun application form or renewal)
b. Requiring the reporting of such issues on a reasonable basis to a firearms licence unit of a local police force
3. The above were described as ‘gaps’ in the legislation which may give rise to the risk of future 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 Failure to require General Practitioner practices to report relevant health issues to firearms licence units
Wider context from the report “1. During the course of evidence it was reflected that Firearms Legislation relating to the holding of a shotgun or firearms licence (or both) contains no provision that a person holding a certificate must self report any illness or mental health condition which may give rise to a change in circumstances from the time when a grant of licence has been made, differing from obligations for example on a person holding a driving licence to do so.
2. Further it was stated that there is no obligation or provision requiring a General Practitioner practice to:
a. Clearly record the holding of a licence on medical records when advised of the grant, in order to assist with flagging any relevant issues that may need reporting (such as conditions listed on an initial firearms/shotgun application form or renewal)
b. Requiring the reporting of such issues on a reasonable basis to a firearms licence unit of a local police force
3. The above were described as ‘gaps’ in the legislation which may give rise to the risk of future death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a self-reporting requirement for firearms certificate holders to report relevant illness or mental health conditions
Wider context from the report “1. During the course of evidence it was reflected that Firearms Legislation relating to the holding of a shotgun or firearms licence (or both) contains no provision that a person holding a certificate must self report any illness or mental health condition which may give rise to a change in circumstances from the time when a grant of licence has been made , differing from obligations for example on a person holding a driving licence to do so.
2. Further it was stated that there is no obligation or provision requiring a General Practitioner practice to:
a. Clearly record the holding of a licence on medical records when advised of the grant, in order to assist with flagging any relevant issues that may need reporting (such as conditions listed on an initial firearms/shotgun application form or renewal)
b. Requiring the reporting of such issues on a reasonable basis to a firearms licence unit of a local police force
3. The above were described as ‘gaps’ in the legislation which may give rise to the risk of future death.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out digital markers for firearms certificate holders across all GP IT systems in England.
Verbatim wording from the response “This process has been further strengthened within GP IT systems, where a GP can add a digital marker to the patient record, to note that the patient has a firearms certificate. This was fully rolled out to all GP IT systems in England by May 2023. If the patient begins to experience a relevant medical condition while the certificate is valid, upon discussion with the GP, the GP will see an alert and upon assessment, can ask the patient to contact the police or the GP can flag this to the police directly, with consent for this provided in the initial application. This allows the police to review the person’s continued suitability, and if necessary, revoke the certificate. Within the existing system there is also provision to record when contact has been made with the police as a result of a digital marker flag.” 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 Existing medical suitability controls, GP markers, and police-reporting arrangements are considered sufficient to address relevant-condition recording and reporting concerns.
Verbatim wording from the response “The Department have worked closely with the Home Office and the British Medical Association to ensure there are strong controls in place in relation to an applicant’s medical suitability which is an important element of the application process that the police consider when deciding if an applicant can hold a firearms or shotgun certificate.” 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 Firearms legislation and certificate-holder self-reporting concerns will be led by the Home Office ministerial colleague.
Verbatim wording from the response “The report raises concerns over firearms legislation relating to shotgun or firearms licensing (or both) and provisions on certificate holders to self-report any illness or mental health condition that may change the circumstances from the time at which the license was granted. My ministerial colleague in the Home Office will lead the response to this concern. The report also raised concerns around the obligation and provision for a General Practitioner to record the holding of a license within medical records to ensure any relevant issues are flagged, and provision for reporting of these issues, by GPs, to the local police force.” Source location Response from Department of Health and Social Care
Open published response
10 Feb 2026 Liam Andrew SUTTON · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 2 Delays in arranging timely appropriate community care packages or alternative placements for medically fit patients View source Failure to transfer patients from the emergency resuscitation area to suitable higher-acuity beds in a timely manner 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
Liam Andrew SUTTON · 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
Liam Sutton became unconscious at home after discharge following a total knee replacement with increased opioid medication, and was subsequently treated for suspected opioid toxicity, pneumonia or sepsis, respiratory complications and acute kidney injury. After intensive care treatment involving ventilation and repeated extubation attempts, he suffered an unresuscitable cardiac arrest during reintubation and died. The principal concerns were prolonged occupancy of the emergency department resuscitation area and hospital bed-blocking linked to delays in discharge and access to appropriate community or care placements.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in arranging timely appropriate community care packages or alternative placements for medically fit patients
Wider context from the report “The court heard in the inquest revealed that the resuscitation department where Mr Sutton was admitted was busy and the evidence indicated that this was and is almost a daily occurrence at the Trust. Mr Sutton remained in the Emergency department resuscitation area for longer than 24 hours and should instead have been transferred to a suitable bed in the hospital. The Intensivist who gave evidence was clear that he should have been transferred to the High Dependency/ Intensive Care department and that patients who are admitted in a timely manner have a much better chance of survival. This also means that bays in the resuscitation department are not free to admit or attend to new acutely ill patients arriving at the hospital.
The court heard that the main issue is trying to discharge a patient to a suitable area in the hospital to free up a cubicle or bay in the resuscitation department. This in turn is due to beds being occupied by patients who are medically fit to be discharged . On any given day we heard that up to a third of the hospital beds can be filled with patients who are fit to leave hospital .
The court heard that the main delay is in discharging patients to appropriate settings or placements and the Trust have taken all steps they can internally to improve the flow of patients through the hospital. From the evidence the court heard it would appear that those responsible for providing care in the community including both the social care providers and the community healthcare providers are not providing either timely appropriate care packages in the patient's home or a bed in an alternative placement be that a nursing home or residential home placement . The evidence suggested that where patients were self funding the delays in discharge were less acute.
This means patients are kept in hospital for longer and thus are more at risk of contracting hospital acquired illnesses themselves which could lead to their own death but are also blocking beds which are needed to treat patients who require acute care in a suitable setting. This is leading to patients being kept longer in the emergency department and reducing available space to receive new critically ill patients. Both of these options can lead to death and there is clearly a risk of death for others requiring clinical care in an acute hospital
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer patients from the emergency resuscitation area to suitable higher-acuity beds in a timely manner
Wider context from the report “The court heard in the inquest revealed that the resuscitation department where Mr Sutton was admitted was busy and the evidence indicated that this was and is almost a daily occurrence at the Trust. Mr Sutton remained in the Emergency department resuscitation area for longer than 24 hours and should instead have been transferred to a suitable bed in the hospital . The Intensivist who gave evidence was clear that he should have been transferred to the High Dependency/ Intensive Care department and that patients who are admitted in a timely manner have a much better chance of survival . This also means that bays in the resuscitation department are not free to admit or attend to new acutely ill patients arriving at the hospital.
The court heard that the main issue is trying to discharge a patient to a suitable area in the hospital to free up a cubicle or bay in the resuscitation department. This in turn is due to beds being occupied by patients who are medically fit to be discharged. On any given day we heard that up to a third of the hospital beds can be filled with patients who are fit to leave hospital.
The court heard that the main delay is in discharging patients to appropriate settings or placements and the Trust have taken all steps they can internally to improve the flow of patients through the hospital. From the evidence the court heard it would appear that those responsible for providing care in the community including both the social care providers and the community healthcare providers are not providing either timely appropriate care packages in the patient's home or a bed in an alternative placement be that a nursing home or residential home placement. The evidence suggested that where patients were self funding the delays in discharge were less acute.
This means patients are kept in hospital for longer and thus are more at risk of contracting hospital acquired illnesses themselves which could lead to their own death but are also blocking beds which are needed to treat patients who require acute care in a suitable setting. This is leading to patients being kept longer in the emergency department and reducing available space to receive new critically ill patients. Both of these options can lead to death and there is clearly a risk of death for others requiring clinical care in an acute hospital
” Open source report
7 Feb 2026 Janet Springall · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 3 Failure to provide timely blood testing for suspected infection in ambulance-held patients View source Failure to provide timely intravenous fluids and antibiotics to ambulance-held patients with suspected infection View source Delays in transferring unwell patients from ambulances to the emergency department 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. 3
Action
Publish national urgent and emergency care, medium-term planning, and 10-year health plans setting priorities for ambulance response, handovers, flow, discharge, and urgent care access.
Stated completedThe respondent said that this action was complete when they made their response on 12 February 2026. View source
Action
Mandate the Release to Rescue approach, requiring ambulance handover to begin at 30 minutes and finish within 45 minutes.
Stated completedThe respondent said that this action was complete when they made their response on 12 February 2026. View source
Action
Continue working with integrated care boards, acute trusts, and ambulance services to deliver the 45-minute handover limit, strengthen urgent community care, and improve hospital flow and discharge.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 February 2026. View source
×
AI-generated summary
Janet Springall · 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
Janet Springall, who had a learning disability and was immunosuppressed, was taken to hospital with pneumonia and sepsis after being found unresponsive. She remained in an ambulance outside the emergency department for almost six hours amid exceptional pressures, and the report raises concern that delays in clinical assessment, blood testing and treatment may place similarly unwell patients at increased 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 Failure to provide timely blood testing for suspected infection in ambulance-held patients
Wider context from the report “My concern is that notwithstanding the hospital Trust seems to have made welcome improvements, patients such as Janet Springall remain at risk.
The Trust continues to experience significant pressures due to patient numbers, and unwell patients continue to remain in ambulances for some time before they are able to access the emergency department.
When a very unwell patient has to remain on an ambulance due to very high demands placed upon a hospital emergency department, believed by paramedics to have a life-threatening infection, then in the absence of a blood test and the timely administration of any necessary intravenous fluids and antibiotics, the chances of such a patient surviving can be significantly reduced by the time the patient is able to access the emergency department.
Janet Springall was very unwell by the time she arrived at hospital and was likely to die. Any realistic prospect she may recover had subsided by around 7.30pm, some 2.5 hours after arrival at hospital.
Other patients may not be as unwell as Janet was upon arrival at hospital, and may therefore have more chance of surviving, but they too may deteriorate significantly whilst remaining in the ambulance before it can be confirmed they have an infection and receive timely medical attention and treatment.
I believe it is necessary for to raise this concern, but it is not for me to be prescriptive about what should / can be done.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely intravenous fluids and antibiotics to ambulance-held patients with suspected infection
Wider context from the report “My concern is that notwithstanding the hospital Trust seems to have made welcome improvements, patients such as Janet Springall remain at risk.
The Trust continues to experience significant pressures due to patient numbers, and unwell patients continue to remain in ambulances for some time before they are able to access the emergency department.
When a very unwell patient has to remain on an ambulance due to very high demands placed upon a hospital emergency department, believed by paramedics to have a life-threatening infection, then in the absence of a blood test and the timely administration of any necessary intravenous fluids and antibiotics , the chances of such a patient surviving can be significantly reduced by the time the patient is able to access the emergency department.
Janet Springall was very unwell by the time she arrived at hospital and was likely to die. Any realistic prospect she may recover had subsided by around 7.30pm, some 2.5 hours after arrival at hospital.
Other patients may not be as unwell as Janet was upon arrival at hospital, and may therefore have more chance of surviving, but they too may deteriorate significantly whilst remaining in the ambulance before it can be confirmed they have an infection and receive timely medical attention and treatment .
I believe it is necessary for to raise this concern, but it is not for me to be prescriptive about what should / can be done.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring unwell patients from ambulances to the emergency department
Wider context from the report “My concern is that notwithstanding the hospital Trust seems to have made welcome improvements, patients such as Janet Springall remain at risk.
The Trust continues to experience significant pressures due to patient numbers, and unwell patients continue to remain in ambulances for some time before they are able to access the emergency department.
When a very unwell patient has to remain on an ambulance due to very high demands placed upon a hospital emergency department , believed by paramedics to have a life-threatening infection, then in the absence of a blood test and the timely administration of any necessary intravenous fluids and antibiotics, the chances of such a patient surviving can be significantly reduced by the time the patient is able to access the emergency department .
Janet Springall was very unwell by the time she arrived at hospital and was likely to die. Any realistic prospect she may recover had subsided by around 7.30pm, some 2.5 hours after arrival at hospital.
Other patients may not be as unwell as Janet was upon arrival at hospital, and may therefore have more chance of surviving, but they too may deteriorate significantly whilst remaining in the ambulance before it can be confirmed they have an infection and receive timely medical attention and treatment.
I believe it is necessary for to raise this concern, but it is not for me to be prescriptive about what should / can be done.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish national urgent and emergency care, medium-term planning, and 10-year health plans setting priorities for ambulance response, handovers, flow, discharge, and urgent care access.
Verbatim wording from the response “NHS England and the Department of Health and Social Care recognise the ongoing pressures across urgent and emergency care, including ambulance services. To improve the quality and timeliness of patient care, the Department of Health and Social Care and NHS England published the 2025/26 Urgent and Emergency Care Plan (June 2025), the Medium Planning Framework 2026-27 to 2028/29 and the 10-Year Health Plan for England: Fit for the Future (July 2025). These set out key system priorities:” Source location Response from Department for 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 Mandate the Release to Rescue approach, requiring ambulance handover to begin at 30 minutes and finish within 45 minutes.
Verbatim wording from the response “Over £370 million in national capital funding supported these improvements. The plans also commit to shifting focus from treatment to prevention, reducing pressure on urgent and emergency care. To ensure timely patient care and release ambulances back into the community, the plan mandates the “Release to Rescue” approach. This requires the handover process to begin at 30 minutes and be completed by 45 minutes.” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with integrated care boards, acute trusts, and ambulance services to deliver the 45-minute handover limit, strengthen urgent community care, and improve hospital flow and discharge.
Verbatim wording from the response “NHS England continues to work with ICBs, acute trusts, and ambulance services to deliver the 45-minute maximum handover requirement, strengthen urgent community care, and improve hospital flow and discharge. Risks associated with long community waits for ambulances are regularly discussed at national forums to support shared understanding and coordinated action across the urgent and emergency care system. The Medium-Term Planning Framework (2026/27–2028/29) sets further ambitions for acute and ambulance collaboration, including progress toward the 15-minute handover standard.” Source location Response from Department for 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 will provide a separate response to the concerns.
Verbatim wording from the response “In preparing this response, my officials have made enquiries with NHS England and Blackpool Teaching Hospital NHS Trust to ensure we adequately address your concerns. CQC have advised they will be providing a separate response to your concerns.” Source location Response from Department for Health and Social Care
Open published response
6 Feb 2026 Mansoor Zaman · Prevention of Future Deaths report East London
View report summary
Concerns raised 11 Failure to reappraise risk to the patient and others in light of erratic behaviour View source Repeated escape from the ward in identical circumstances View source Failure to use the required emergency 999 number for the report View source Failure to adequately document observations and care decisions View source Failure to reassess the frequency and quality of required observations View source Failure of the duty doctor to impose an S.5(2) MHA 1983 authorisation when indicated View source Delays in reporting an absconded patient as missing to the police View source Patient safety investigations failing to seek treating staff recollections View source Inaccurate categorisation of risk as medium after a patient absconds View source Failure to instigate an S.5(4) MHA 1983 authorisation when a patient returns after absconding View source Failure to communicate patient safety investigation findings to treating staff View source See 8 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
Mansoor Zaman · 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
Mansoor Zaman, a 27-year-old man with a history of suicidality, substance misuse and EUPD, absconded from a mental health ward on 8 December 2024 after displaying suicidal intent and erratic and aggressive behaviour. His body was recovered on 29 December 2024. The substantive concerns included failures to use available mental health authorisations, reassess risk and observation levels, adequately document care, and promptly report him missing to police; the inquest jury identified some of these failures as factors that probably or possibly contributed to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to reappraise risk to the patient and others in light of erratic behaviour
Wider context from the report “3. The failure of Trust staff to reappraise the level of risk presented by Mr Zaman to himself and others in light of his erratic behaviour on 8th December 2024 , specifically,
a. His escape from the ward by violently kicking the fire exit door.
b. His aggression toward the duty doctor during assessment.
c. His assault upon a member of ward staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Repeated escape from the ward in identical circumstances
Wider context from the report “4. His second escape from the ward in identical circumstances to the first. The failure of Trust staff to re-assess the frequency and quality of observations that Mr Zaman should be subject to during the afternoon of 8th December 2024.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 the required emergency 999 number for the report
Wider context from the report “8. The use of the police 101 number as opposed to the required emergency 999 number to make the report.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 adequately document observations and care decisions
Wider context from the report “2. The failure of nursing staff on the ward to adequately document observations and care decisions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to reassess the frequency and quality of required observations
Wider context from the report “4. His second escape from the ward in identical circumstances to the first. The failure of Trust staff to re-assess the frequency and quality of observations that Mr Zaman should be subject to during the afternoon of 8th December 2024.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 duty doctor to impose an S.5(2) MHA 1983 authorisation when indicated
Wider context from the report “5. The failure of the duty doctor to act decisively and impose an authorisation under S.5 (2) MHA 1983 having been presented with an agitated patient who had minutes before escaped from the ward.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in reporting an absconded patient as missing to the police
Wider context from the report “6. The dilatory response of staff on the ward to report Mr Zaman as a missing person to the police , an action that did not happen for almost three hours after it was known that he had absconded .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Patient safety investigations failing to seek treating staff recollections
Wider context from the report “9. The inadequacy of the Trust patient safety framework investigation which neither sought the recollections of treating staff , nor communicated the findings of the report to the same staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 categorisation of risk as medium after a patient absconds
Wider context from the report “7. The categorisation of the risk presented by Mr Zaman as of a medium level by the nurse in charge when considering action to be taken after he absconded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 instigate an S.5(4) MHA 1983 authorisation when a patient returns after absconding
Wider context from the report “1. The failure of nurses on the ward to instigate an authorisation under S.5(4) MHA 1983 when Mr Zaman returned to the ward after absconding on the afternoon of 8th December 2024.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 patient safety investigation findings to treating staff
Wider context from the report “9. The inadequacy of the Trust patient safety framework investigation which neither sought the recollections of treating staff, nor communicated the findings of the report to the same staff.
” Open source report
Concerns raised 3 Significant delays in hospital ambulance handover View source Limited social care provision affecting patient flow View source Delays in emergency ambulance arrival during periods of significant demand 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 Frances Darlow · 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 Frances Darlow suffered a stroke at home on 6 January 2025, but an ambulance arrived 23 hours and 20 minutes later. She was diagnosed with an extensive left middle cerebral artery infarct, was not suitable for thrombectomy because of the delay, and died in hospital on 7 June 2025. The principal concern was the prolonged ambulance delay, in the context of high demand, hospital handover delays, patient flow and limited social care provision, resulting in lost opportunities for investigation and potential treatment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Significant delays in hospital ambulance handover
Wider context from the report “Category of Concern – Emergency Services Related Death; Ambulance Delays (resources)
Angela Darlow was suffering from symptoms of a stroke at home during the afternoon of 6 January 2025. Her husband immediately contacted the Welsh Ambulance Service via 999. Given the significant demand at this time, it took 23 hours and 20 minutes for an emergency ambulance to attend. The calls made to the Trust were correctly categorised. By the time Angela arrived at the nearest hospital, The Countess of Chester, she was outside the time for investigations for thrombectomy.
At the time in question demand was unprecedented. This is reflected by the 23 hour and 20 minute delay in ambulance arriving.
There were significant hospital handover delays at the time which added to the demand on the Trust .
The facts in Angela’s death speak for themselves. I continue to remain concerned about the time is taking for ambulances to arrive in the context of the multifactorial reasons for this which include patient flow in hospitals and limited social care provision. People are dying due to these issues and yet we are no closer to improvement.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 social care provision affecting patient flow
Wider context from the report “Category of Concern – Emergency Services Related Death; Ambulance Delays (resources)
Angela Darlow was suffering from symptoms of a stroke at home during the afternoon of 6 January 2025. Her husband immediately contacted the Welsh Ambulance Service via 999. Given the significant demand at this time, it took 23 hours and 20 minutes for an emergency ambulance to attend. The calls made to the Trust were correctly categorised. By the time Angela arrived at the nearest hospital, The Countess of Chester, she was outside the time for investigations for thrombectomy.
At the time in question demand was unprecedented. This is reflected by the 23 hour and 20 minute delay in ambulance arriving.
There were significant hospital handover delays at the time which added to the demand on the Trust.
The facts in Angela’s death speak for themselves. I continue to remain concerned about the time is taking for ambulances to arrive in the context of the multifactorial reasons for this which include patient flow in hospitals and limited social care provision . People are dying due to these issues and yet we are no closer to improvement.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in emergency ambulance arrival during periods of significant demand
Wider context from the report “Category of Concern – Emergency Services Related Death; Ambulance Delays (resources)
Angela Darlow was suffering from symptoms of a stroke at home during the afternoon of 6 January 2025. Her husband immediately contacted the Welsh Ambulance Service via 999. Given the significant demand at this time, it took 23 hours and 20 minutes for an emergency ambulance to attend . The calls made to the Trust were correctly categorised. By the time Angela arrived at the nearest hospital, The Countess of Chester, she was outside the time for investigations for thrombectomy.
At the time in question demand was unprecedented . This is reflected by the 23 hour and 20 minute delay in ambulance arriving .
There were significant hospital handover delays at the time which added to the demand on the Trust.
The facts in Angela’s death speak for themselves. I continue to remain concerned about the time is taking for ambulances to arrive in the context of the multifactorial reasons for this which include patient flow in hospitals and limited social care provision. People are dying due to these issues and yet we are no closer to improvement.
” Open source report
5 Feb 2026 Kallum Josh REED · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Failure of mental health professionals to work collaboratively to find a safe crisis-care solution View source Unacceptably long waits for ASD and ADHD referrals, assessments and diagnoses View source No route to access halfway-house care except via the crisis team View source Crisis team gatekeeping and rejection of referrals for crisis care View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kallum Josh REED · 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
Kallum Josh REED died after being found fully suspended during a police search following his disappearance on 11 February 2025. The report raises concerns about delays in autism spectrum disorder and ADHD referrals, assessments and diagnoses, and about crisis-care referral pathways and coordination between mental health services.
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 mental health professionals to work collaboratively to find a safe crisis-care solution
Wider context from the report “(2) The second concern is that the court was told that the "crisis team" gate-keep referrals into their service, notwithstanding that referral requests can often arise from psychiatry liaison and/or the community psychiatric team who have deep knowledge of the patient and have conducted their own detailed assessments. The care planning in Kallum's case advised him to contact the single point of access (who had rejected referral back to the crisis team in the weeks preceding the death), to present to ED (which he did but was discharged home to remain under the community team).
The pathways essentially failed as the crisis team still able to reject the referral, thus effectively closing down an avenue for ongoing close care and communication as the crisis presentation continued. The Trust's internal report concluded that Kallum should have been assessed in person and probably should have been accepted back by the crisis team, but in court this conclusion was contested by the service manager. His evidence was that the crisis team was not appropriate for Kallum and the community team should continue the care. This re-emphasised the challenges faced by patients seeking crisis care as the Trust's own professionals were not in agreement or working collaboratively to find a safe solution . The situation appears not to have changed in the 12 months following this death .
There appears to be no route to access the "half way house" provisions of care unless via the crisis team and so these were not offered or discussed with Kallum or his family who were trying to care for him.
I am therefore raising this concern with the WLNHS Trust
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unacceptably long waits for ASD and ADHD referrals, assessments and diagnoses
Wider context from the report “(1) The first concern is the "unacceptably long wait" for referrals, assessments and diagnoses of ASD and ADHD . The court was told that demand is continuing to outstrip the services ability to cope ; services are outsourced to private providers but there are still unacceptable delays . This impacts the provision of care, the provision of appropriate medication, providing the individuals with insight and understanding of their own presentations and the provision of professional support. In Kallum's case this contributed to the factors that caused his death. I am therefore raising this concern with the Minister for the DHSC and the WLNHS Trust
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation No route to access halfway-house care except via the crisis team
Wider context from the report “(2) The second concern is that the court was told that the "crisis team" gate-keep referrals into their service, notwithstanding that referral requests can often arise from psychiatry liaison and/or the community psychiatric team who have deep knowledge of the patient and have conducted their own detailed assessments. The care planning in Kallum's case advised him to contact the single point of access (who had rejected referral back to the crisis team in the weeks preceding the death), to present to ED (which he did but was discharged home to remain under the community team).
The pathways essentially failed as the crisis team still able to reject the referral, thus effectively closing down an avenue for ongoing close care and communication as the crisis presentation continued. The Trust's internal report concluded that Kallum should have been assessed in person and probably should have been accepted back by the crisis team, but in court this conclusion was contested by the service manager. His evidence was that the crisis team was not appropriate for Kallum and the community team should continue the care. This re-emphasised the challenges faced by patients seeking crisis care as the Trust's own professionals were not in agreement or working collaboratively to find a safe solution. The situation appears not to have changed in the 12 months following this death.
There appears to be no route to access the "half way house" provisions of care unless via the crisis team and so these were not offered or discussed with Kallum or his family who were trying to care for him.
I am therefore raising this concern with the WLNHS Trust
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Crisis team gatekeeping and rejection of referrals for crisis care
Wider context from the report “(2) The second concern is that the court was told that the "crisis team" gate-keep referrals into their service , notwithstanding that referral requests can often arise from psychiatry liaison and/or the community psychiatric team who have deep knowledge of the patient and have conducted their own detailed assessments. The care planning in Kallum's case advised him to contact the single point of access (who had rejected referral back to the crisis team in the weeks preceding the death), to present to ED (which he did but was discharged home to remain under the community team).
The pathways essentially failed as the crisis team still able to reject the referral, thus effectively closing down an avenue for ongoing close care and communication as the crisis presentation continued . The Trust's internal report concluded that Kallum should have been assessed in person and probably should have been accepted back by the crisis team, but in court this conclusion was contested by the service manager. His evidence was that the crisis team was not appropriate for Kallum and the community team should continue the care. This re-emphasised the challenges faced by patients seeking crisis care as the Trust's own professionals were not in agreement or working collaboratively to find a safe solution. The situation appears not to have changed in the 12 months following this death.
There appears to be no route to access the "half way house" provisions of care unless via the crisis team and so these were not offered or discussed with Kallum or his family who were trying to care for him.
I am therefore raising this concern with the WLNHS Trust
” 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 universal access to urgent mental health helplines through NHS 111 and alternative crisis services.
Verbatim wording from the response “More widely Government has been working to build more robust crisis care pathways across all ages ensuring that people in mental health crisis have access to timely and appropriate support. Key developments include:” Source location 2026-0061 - Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest up to £120 million to expand mental health emergency departments to 85.
Verbatim wording from the response “• Investing up to £120m to bring the number of mental health emergency departments up to 85. Mental Health Emergency Departments will provide reactive, short term intensive support for people in acute MH crisis as an alternative to A&E. Mental Health Emergency Departments, or Crisis Assessment Centres, are specialist NHS services that operate alongside emergency departments to provide access to high quality, safe and compassionate care for those in mental health crisis. Crisis Assessment Centres will be usually accessed via self-referral, direct referral from other UEC mental health services, or ‘a walk-in’ where patients choose to do so.” Source location 2026-0061 - 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 Transform mental health services into community-based mental health centres bringing crisis services and short-stay beds together.
Verbatim wording from the response “To help ensure that fewer people reach a point of crisis, the government is transforming mental health services into community-based mental health centres, building on existing pilots. These centres will bring together a range of community mental health services under one roof, including crisis services and short-stay beds, improving continuity of care. This reduces fragmentation in service delivery and patient experience, which contributes to longer waiting times and lower patient satisfaction.” Source location 2026-0061 - Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest in training professionals in autism and ADHD diagnostic assessment.
Verbatim wording from the response “While I acknowledge that there is still more to do, I can report that waiting times for assessment for potential autism in adults have fallen in the past twelve months nationally across ICB catchment areas. We believe that this progress has been aided by the ‘Right to Choose’ pathway provided by ICBs which gives patients in England the right to choose which NHS-commissioned provider they are referred to for a first outpatient appointment for ASD (and ADHD) diagnostic assessment, allowing people to access providers offering shorter waiting times. Over the last 2 years NHSE has also invested in training a range of professionals in diagnostic assessment.” Source location 2026-0061 - 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 West London NHS Trust is handling the specific local issues arising from Kallum’s death and responding separately to the report.
Verbatim wording from the response “In terms of the specific local issues that resulted in Kallum slipping between the gaps and not receiving the potentially life-saving care he needed, I understand that West London NHS Trust has undertaken a Patient Safety Incident Investigation to learn important lessons from this event, which I welcome. I believe that they are responding separately to your report.” Source location 2026-0061 - 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 Integrated care boards are responsible for providing appropriate local autism services in line with relevant NICE guidelines.
Verbatim wording from the response “It is the responsibility of integrated care boards (ICBs) to make available appropriate provision to meet the health and care needs of their local population, including provision of autism services, in line with relevant National Institute for Health and Care Excellence (NICE) guidelines.” Source location 2026-0061 - Response from Department of Health and Social Care
Open published response
28 Jan 2026 Akhona MOYO · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1 Lack of hospital doctors’ electronic access to detailed primary care medical notes 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
Akhona MOYO · 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
Akhona Moyo, aged 4, died on 26 November 2022 at Queens Medical Centre, Nottingham, from a brain tumour. The principal concern was that hospital doctors lacked electronic access to detailed primary care records, which the evidence indicated would assist in delivering better treatment and care, particularly for patients who are autistic and non-verbal.
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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 hospital doctors’ electronic access to detailed primary care medical notes
Wider context from the report “Hospital doctors, including in the Emergency Department and Paediatrics, do not have electronic access to primary care medical notes e.g. GP notes, community mental health notes etc. At Northampton General Hospital, a new electronic system known as “Nerve Centre” contains only hospital notes . Hospital doctors also have access to the “Northamptonshire Care Record” which contains basic lists of GP visits and medication, but no detailed entries .
All the doctors that gave evidence to the Inquest stated that access to primary care records would undoubtedly assist them in delivering better patient treatment and care. It was felt that access to such information was particularly important in cases such as the present when a patient is autistic and non-verbal. There may be a multitude of other reasons why a patient or their family may not be able to relay to doctors a full and accurate medical history. Access may also enable doctors to have a more global view of a patient’s medical condition rather than, as it was put at Inquest, “working in silos”.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Single Patient Record to unify patient data from multiple sources and provide clinicians access through existing clinical systems.
Verbatim wording from the response “I agree that ensuring health and care professionals have access to a single source of digital information about the patients they are treating and caring for is vitally important to delivering the best care possible. The Department of Health and Social Care, and NHS England have programmes of work underway which should assist in preventing future deaths connected to this issue.” Source location 2026-0045 - Response from DHSC
Open published response
27 Jan 2026 Pippa Isobel Waller GILLIBRAND · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 9 Lack of national or local home birth data collection View source Lack of guidance on the threshold for transfer from home birth to hospital View source Lack of guidance on midwife training for competent home birth management View source Lack of guidance on information for expectant parents about home birth risks and team experience View source Lack of guidance on midwife experience requirements for home birth management View source Lack of guidance on backup arrangements for electronic system failure during home births View source Lack of guidance on safe home birth staffing and equipment levels View source Lack of guidance on supervision during home births View source Lack of national guidance on the home birth model of care View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Pippa Isobel Waller GILLIBRAND · 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
Pippa Isobel Waller Gillibrand was delivered by forceps in poor condition after a home birth was continued despite staffing, equipment and fetal heart-rate monitoring issues, and she later died in hospital from a severe irreversible brain injury. The report identified concerns about the lack of guidance on home-birth staffing, midwife competence, transfer thresholds, equipment, supervision, electronic-recording failures and information for parents, as well as the absence of national or local home-birth outcome data.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national or local home birth data collection
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on the threshold for transfer from home birth to hospital
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on midwife training for competent home birth management
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth , given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on information for expectant parents about home birth risks and team experience
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on midwife experience requirements for home birth management
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on backup arrangements for electronic system failure during home births
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on safe home birth staffing and equipment levels
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on supervision during home births
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on the home birth model of care
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” 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 NHS England holds operational responsibility for homebirth guidance, data collection and training, and will address these concerns.
Verbatim wording from the response “You raise concerns over the lack of national guidance for home births, particularly the model of care, as well as concerns that there is no national or local collection of data around home births. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns, and I understand there is work underway to develop national standards and a clear framework for homebirth services. As operational responsibility for issuing guidance and collecting data around home births sits with NHS England, they will be issuing a substantive response addressing the specific matters of concern raised.” Source location 2026-0042 - Response from DHSC
Open published response
Concerns raised 2 Lack of defined boundaries and guidance for doula interactions with maternity services View source Lack of regulation of doula care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Matilda Pomfret Thomas · 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
Matilda Pomfret Thomas died aged 15 days from hypoxic ischaemic encephalopathy after a difficult home labour in which fetal distress and meconium were observed, but transfer to hospital did not occur until later. The principal concern was the lack of regulation, registration, training and guidance for doulas, including how their role should interact with midwifery services.
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 defined boundaries and guidance for doula interactions with maternity services
Wider context from the report “Doulas provide continuity of care and give emotional, informational and practical support throughout pregnancy, labour and after the birth of a baby: those words come from Doula UK’s website. Doula UK is the largest representative body for Doulas, but it is not a regulatory body, it does not represent all doulas, indeed many doulas are not members of Doula UK. Doula UK have put in place membership requirements, training offers and much guidance, but the role of a doula is clearly diffuse in practical terms and capable of multiple understandings not just by doulas but their clients and midwives .
It appears that doulas have been increasingly used and increasingly offer services - as here - on a paid basis.
As MNSI (Maternity & Newborn Safety Investigations - formerly HSIB) put it in their report into this birth, “MNSI acknowledges that there is no regulation of doula care or any guidance on how the two services interact with each other . MNSI considers the dynamics of a situation, where a third party are involved can provide additional challenges for staff, such as making clinical recommendations against personal recommendations or views and providing usual care that could be viewed as interference rather than surveillance.”
MNSI have identified 12 cases in which there was evidence that doulas worked outside of the defined boundaries of their role and in which the care or advice provided by the doula was considered to have potentially had an influence on the poor outcome for the family.
There was evidence given at the inquest by experienced midwifery professionals highlighting that provision of guidance would be helpful for all involved with a birth at which a doula was present .
The issues of doula registration, regulation and training are therefore points of concern I would commend for review.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of regulation of doula care
Wider context from the report “Doulas provide continuity of care and give emotional, informational and practical support throughout pregnancy, labour and after the birth of a baby: those words come from Doula UK’s website. Doula UK is the largest representative body for Doulas, but it is not a regulatory body , it does not represent all doulas, indeed many doulas are not members of Doula UK. Doula UK have put in place membership requirements, training offers and much guidance, but the role of a doula is clearly diffuse in practical terms and capable of multiple understandings not just by doulas but their clients and midwives.
It appears that doulas have been increasingly used and increasingly offer services - as here - on a paid basis.
As MNSI (Maternity & Newborn Safety Investigations - formerly HSIB) put it in their report into this birth, “MNSI acknowledges that there is no regulation of doula care or any guidance on how the two services interact with each other. MNSI considers the dynamics of a situation, where a third party are involved can provide additional challenges for staff, such as making clinical recommendations against personal recommendations or views and providing usual care that could be viewed as interference rather than surveillance.”
MNSI have identified 12 cases in which there was evidence that doulas worked outside of the defined boundaries of their role and in which the care or advice provided by the doula was considered to have potentially had an influence on the poor outcome for the family.
There was evidence given at the inquest by experienced midwifery professionals highlighting that provision of guidance would be helpful for all involved with a birth at which a doula was present.
The issues of doula registration, regulation and training are therefore points of concern I would commend for review.
” 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 NHS England will not produce guidance on midwives’ interactions with doulas because doulas are unregulated and their support has no additional status.
Verbatim wording from the response “That said, Doulas must not undertake midwifery or other clinical care. Given the unregulated nature of the Doula role, and that the support they give during labour and birth carries no additional status than for anyone else, NHS England will not be producing guidance for midwives’ interactions with doulas.” 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 Independent doula-register organisations are outside Government oversight, so their practice requirements are not a Government decision.
Verbatim wording from the response “Any organisation that holds a register for doulas is an independent, representative body and as such, they do not fall under Government oversight. Therefore, any decisions about the practice requirements for the professions they represent are a matter for those organisations and their members.” Source location Response from Department of Health and Social Care
Open published response
14 Jan 2026 Dorothy Margaret Hoyberg · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to maintain welfare calls at least every 30 minutes View source Insufficient ambulance service capacity causing delays in ambulance responses 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
Dorothy Margaret Hoyberg · 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
Dorothy Margaret Hoyberg called emergency services with worsening severe leg, abdominal and back pain and was assessed as requiring a Category 3 ambulance response. The ambulance arrived five and a half hours later, and she was found deceased; post-mortem toxicology showed elevated morphine and methadone levels, and the inquest determined that her death was drug related. The principal concern was the prolonged ambulance delay during extreme pressure on ambulance services, with insufficient capacity for regular welfare call-backs.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain welfare calls at least every 30 minutes
Wider context from the report “On 19 June 2025 London Ambulance Service (LAS) were operating at REAP Level 4 (extreme pressure) and by 9am that day, targets were being breached. Multiple attempts were made to find an ambulance resource for Dorothy but LAS were unable to meet targets for Category 3 patients and were struggling to meet targets for Category 2 patients. Welfare calls were made to Dorothy until 12:25 at which point the demand on LAS was so high that there was no capacity to make any further welfare calls . Ideally welfare calls should have been made at least every 30 minutes but it was necessary for LAS to prioritise demand and deploy clinicians where they were most needed. Demand outstripped capacity. An ambulance should have reached Dorothy within two hours but it took five and half.
I heard evidence that this is a pan-London problem, and it does not appear to be restricted to London. The demand on ambulance services is increasing and the number of patients requiring their services is increasing. Ambulance services are under extreme pressure and this is causing a systems challenge and long delays for patients.
LAS are currently operating at REAP Level 4.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient ambulance service capacity causing delays in ambulance responses
Wider context from the report “On 19 June 2025 London Ambulance Service (LAS) were operating at REAP Level 4 (extreme pressure) and by 9am that day, targets were being breached. Multiple attempts were made to find an ambulance resource for Dorothy but LAS were unable to meet targets for Category 3 patients and were struggling to meet targets for Category 2 patients . Welfare calls were made to Dorothy until 12:25 at which point the demand on LAS was so high that there was no capacity to make any further welfare calls. Ideally welfare calls should have been made at least every 30 minutes but it was necessary for LAS to prioritise demand and deploy clinicians where they were most needed. Demand outstripped capacity . An ambulance should have reached Dorothy within two hours but it took five and half .
I heard evidence that this is a pan-London problem, and it does not appear to be restricted to London. The demand on ambulance services is increasing and the number of patients requiring their services is increasing. Ambulance services are under extreme pressure and this is causing a systems challenge and long delays for patients.
LAS are currently operating at REAP Level 4.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the 2025/26 Urgent and Emergency Care Plan to improve ambulance response times and patient flow.
Verbatim wording from the response “To prioritise and improve the quality and timeliness of patient care, the Department of Health and Social Care and NHS England published the 2025/26 Urgent and Emergency Care Plan (June 2025) and the 10 Year Health Plan for England: Fit for the Future (July 2025). The Urgent and Emergency Care Plan commits to reducing mean ambulance response times for Category 2 patients by over 14%, to 30 minutes and improving the clinical validation of Category 3 and 4 calls. To achieve this, we recognise we will need to make improvements to patient flow through the whole system, and the plan outlines a set of priority actions to support systems to maximise patient flow, including:” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the 10 Year Health Plan for England, setting a trajectory towards prevention and reduced urgent-care demand.
Verbatim wording from the response “To prioritise and improve the quality and timeliness of patient care, the Department of Health and Social Care and NHS England published the 2025/26 Urgent and Emergency Care Plan (June 2025) and the 10 Year Health Plan for England: Fit for the Future (July 2025). The Urgent and Emergency Care Plan commits to reducing mean ambulance response times for Category 2 patients by over 14%, to 30 minutes and improving the clinical validation of Category 3 and 4 calls. To achieve this, we recognise we will need to make improvements to patient flow through the whole system, and the plan outlines a set of priority actions to support systems to maximise patient flow, including:” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue coordinating with commissioners, integrated care boards, providers and ambulance services to deliver urgent and emergency care improvement plans.
Verbatim wording from the response “NHS England actions
NHS England continues to work closely with commissioners, Integrated Care Boards, acute providers, and ambulance services, including London Ambulance Service, to support delivery of stretching but achievable plans aligned with operational priorities. The risks associated with community waits for ambulances have been discussed at national forums to support shared understanding and coordinated action across urgent and emergency care pathways on measures such as implementing the 45-minute maximum handover requirement; expanding urgent community care provision; reducing length of stay; and supporting timely patient discharge. These measures are designed to maintain patient flow, reduce emergency department crowding and facilitate prompt ambulance handovers.” 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 Implement dedicated clinical support linked to dispatch to identify incidents requiring prioritisation of clinical resources.
Verbatim wording from the response “The LAS maintains a performance recovery plan, which is regularly updated in response to changes in the demand profile and system pressures. This includes the implementation of dedicated clinical support linked to dispatch to identify incidents where allocation of a clinical resource may need to be prioritised.” 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 Introduce hospital handover-delay mitigation by directing crews to hospitals with greater capacity and cohorting patients when necessary.
Verbatim wording from the response “London Ambulance Service Trust Actions
The LAS has introduced multiple processes to mitigate the issue of hospital handover delay for example: directing crews conveying patients towards hospitals with greater capacity and cohorting patients at hospitals (two or three staff taking responsibility for additional patients, so that other crews can become available for calls more quickly) where necessary. The Trust is currently in the middle of its five-year strategy (2023-2028). This strategy aims to forge closer links between Primary and Acute care sectors and Local Authorities, ensuring the right care is provided at the right time, including the development and referral to alternative care pathways avoiding the need to convey to hospital when appropriate.” 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 Allocate national capital funding for urgent treatment centres, same-day emergency care expansion and new ambulances.
Verbatim wording from the response “More than £370 million of capital funding has been allocated nationally to support implementation, including £250 million of capital budget to continue the expansion of co-located urgent treatment centres and same day emergency care, and £75 million capital funding for new ambulances. The 10 Year Plan for England also sets out a clear trajectory towards shifting from treatment to prevention, reducing overall demand for urgent care.” 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 national growth funding to ambulance services to support activity and service improvement.
Verbatim wording from the response “In 2025/26, all ambulance services received national growth funding to support activity levels and incentivise service improvement. Performance improvements have been observed in LAS, between January 2025 and January 2026:” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain and regularly update the performance recovery plan in response to demand and system pressures.
Verbatim wording from the response “The LAS maintains a performance recovery plan, which is regularly updated in response to changes in the demand profile and system pressures. This includes the implementation of dedicated clinical support linked to dispatch to identify incidents where allocation of a clinical resource may need to be prioritised.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and refer patients to alternative care pathways, where appropriate, to avoid conveyance to hospital.
Verbatim wording from the response “London Ambulance Service Trust Actions
The LAS has introduced multiple processes to mitigate the issue of hospital handover delay for example: directing crews conveying patients towards hospitals with greater capacity and cohorting patients at hospitals (two or three staff taking responsibility for additional patients, so that other crews can become available for calls more quickly) where necessary. The Trust is currently in the middle of its five-year strategy (2023-2028). This strategy aims to forge closer links between Primary and Acute care sectors and Local Authorities, ensuring the right care is provided at the right time, including the development and referral to alternative care pathways avoiding the need to convey to hospital when appropriate.” Source location Response from Department of Health and Social Care
Open published response
14 Jan 2026 Oliver Anderson Long · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 5 Failure of consumers to check gambling-site licensing before access View source Failure of the self-exclusion scheme to cover overseas unlicensed gambling sites View source Lack of consumer awareness when accessing unlicensed gambling sites View source Lack of adequate public health information and warnings about unlicensed gambling-site risks View source Absence of gambling-harm protection features on unlicensed sites 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
Oliver Anderson Long · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Oliver Anderson Long, known as Ollie, was found dead on 23 February 2024 after travelling to East Sussex and leaving notes indicating an intention to take his own life from cliffs. He had a history including gambling disorder and, despite self-exclusion from licensed online gambling, was able to access unlicensed gambling sites. The principal concern was that unlicensed sites are outside the protections of regulated gambling and that there is inadequate public health information and warning about their risks.
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 consumers to check gambling-site licensing before access
Wider context from the report “Consumers are unlikely to check that a site is licenced prior to accessing it , particularly if the advert for the site is in a trusted space, such as on social media . The result is that people who are at risk of gambling-related harm in accessing these sites are not protected by features such as limit setting and slowing down of gains, and they may not be aware that these features are unlikely to be present on the site they are using.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 self-exclusion scheme to cover overseas unlicensed gambling sites
Wider context from the report “I heard evidence from Ollie's family and the Gambling Commission in respect of the efficacy of the UK self-exclusion scheme, GamStop, which allows customers to bar themselves from all forms of legal and licenced online betting. This scheme, however, does not capture overseas unlicensed sites and people who have self-excluded (as Ollie did) may be able to access these sites or are being deliberately targeted by them .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of consumer awareness when accessing unlicensed gambling sites
Wider context from the report “Additionally, I heard evidence that consumers may not be aware that they have accessed an unlicensed site and in doing so have moved outside of the realm of the regulated area .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate public health information and warnings about unlicensed gambling-site risks
Wider context from the report “There is, in my view, a lack of adequate public health information and warning relating to the risks posed by unlicenced gambling sites .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 gambling-harm protection features on unlicensed sites
Wider context from the report “Consumers are unlikely to check that a site is licenced prior to accessing it, particularly if the advert for the site is in a trusted space, such as on social media. The result is that people who are at risk of gambling-related harm in accessing these sites are not protected by features such as limit setting and slowing down of gains , and they may not be aware that these features are unlikely to be present on the site they are using .
” 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 DCMS, as lead department for gambling policy and regulation, will lead and submit the cross-agency response on behalf of the named organisations.
Verbatim wording from the response “In relation to the matters of concern set out in your report, DCMS, as the lead government department responsible for gambling policy and regulation, is leading the development of a single cross-agency response, working collaboratively with relevant policy officials across the named organisations. DHSC fully supports this approach and is actively contributing to the response, particularly in respect of public health considerations.” Source location Response from Department of Health and Social Care
Open published response
28 Dec 2025 Mohamed Abdisamad · Prevention of Future Deaths report West London
View report summary
Concerns raised 6 Failure to obtain consent before NTMC View source Lack of infection control requirements for NTMC View source Lack of external accreditation and registration for NTMC practitioners View source Lack of record-keeping requirements for NTMC View source Lack of training and continuing professional development requirements for NTMC practitioners View source Lack of aftercare requirements for NTMC 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
Mohamed Abdisamad · 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
Mohamed Abdisamad underwent a non-therapeutic male circumcision on 12 February 2023 and developed symptoms of illness three to four days later. He suffered a cardiorespiratory arrest while being taken to hospital and was declared dead on 19 February 2023; the inquest recorded invasive Streptococcus pyogenes infection following male circumcision as the medical cause of death. The report raised concerns about the lack of training, accreditation, record keeping, consent, infection-control requirements and aftercare requirements for individuals conducting such procedures.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain consent before NTMC
Wider context from the report “4. There is no system for consent to be taken prior to a Non-Therapeutic Male Circumcisions (NTMC) .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 infection control requirements for NTMC
Wider context from the report “5. There is no requirement for any infection control measures for a Non-Therapeutic Male Circumcisions (NTMC).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 external accreditation and registration for NTMC practitioners
Wider context from the report “2. There is no system of external accreditation and/or registration for individuals who conduct a Non-Therapeutic Male Circumcisions (NTMC).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 record-keeping requirements for NTMC
Wider context from the report “3. There is no requirement for any record keeping for individuals who undergo a Non-Therapeutic Male Circumcisions (NTMC).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 continuing professional development requirements for NTMC practitioners
Wider context from the report “1. Any individual may conduct a Non-Therapeutic Male Circumcision (NTMC) without any prior training or any Continuing Professional Development (CDP) ,
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 aftercare requirements for NTMC
Wider context from the report “6. There are no requirements for any aftercare for a Non-Therapeutic Male Circumcisions (NTMC) , including but not limited to dressing the wound, analgesia and/or worsening care advice .
” 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 Circumcisions performed by non-registered healthcare professionals, including non-therapeutic procedures, fall outside CQC regulatory scope.
Verbatim wording from the response “The CQC provides oversight of services provided by registered health professionals performing male circumcision, ensuring consistent standards of safety and quality in those cases. This includes both therapeutic and non-therapeutic male circumcision. Circumcision carried out by individuals who are not registered healthcare professionals remain outside of CQC regulatory scope. This includes any non-therapeutic circumcision, regardless of the purposes for carrying out the circumcision.” 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 Existing professional regulation and CQC registration provide safety and quality oversight when regulated healthcare professionals perform male circumcision.
Verbatim wording from the response “If an NTMC procedure is carried out by a regulated healthcare professional, they will be subject to oversight by the relevant professional regulator such as the GMC for” 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 Existing law requires valid consent before non-therapeutic male circumcision, including consent from a person with parental responsibility where applicable.
Verbatim wording from the response “It is a general legal and ethical principle that valid consent must be obtained from an individual before starting a treatment or physical intervention. For consent to be valid it must be given voluntarily by an appropriately informed person who has the capacity to consent to the intervention in question. If children have the capacity to give consent for themselves, consent should be sought directly from them. Once young people reach the age of 16, they are presumed in law to be competent to give consent for themselves for their own surgical, medical or dental treatment, and any associated procedures, such as investigations, anaesthesia or nursing care. If a child is not competent to give consent for themselves, consent should be sought from a person with parental responsibility. This will often, but not always, be the child’s parent.” Source location Response from Department of Health and Social Care
Open published response
17 Dec 2025 Dr Debapriya Ghosh and Mr David Albert Ward · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 4 Insufficient effectiveness of measures to manage A&E demand and risk View source Failure to provide safe supervision for patients in overcrowded A&E departments View source Insufficient A&E staffing to manage demand during busy periods View source A&E staff stress and retention failures associated with staff and resource shortages View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dr Debapriya Ghosh and Mr David Albert Ward · 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 Debapriya Ghosh and Mr David Albert Ward died at St George’s Hospital after falls causing traumatic head injuries while they were being treated in a busy A&E department. The report raised concerns about insufficient staffing and resources, inadequate nursing risk assessment and supervision, reliance on families to supervise patients, and the resulting risks in overcrowded A&E departments.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient effectiveness of measures to manage A&E demand and risk
Wider context from the report “3. That local hospitals such as St George’s have implemented multiple actions within their power to attempt to manage demand and risk , but these have been insufficient such that risk remains , and so consideration should be given to the issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 safe supervision for patients in overcrowded A&E departments
Wider context from the report “4. That it is unsafe for families to leave their loved ones unsupervised in overcrowded A&E departments .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient A&E staffing to manage demand during busy periods
Wider context from the report “1. That St George’s Hospital and other hospital A&E departments have insufficient staff to manage demand during busy periods such that nursing risk cannot be managed without relying on 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 A&E staff stress and retention failures associated with staff and resource shortages
Wider context from the report “2. That at work stress on A&E staff due to staff and resource shortages may cause them to leave the profession exacerbating shortages of experienced staff and thus increase risks in A&E .
” 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 Increase urgent care capacity outside hospitals through new neighbourhood health services.
Verbatim wording from the response “• In the longer-term, our 10 Year Health Plan will increase the urgent care capacity outside hospital through new neighbourhood health services, reducing demand pressures on A&E.” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase urgent care delivered in primary, community and mental health settings.
Verbatim wording from the response “• Increasing the number of patients receiving urgent care in primary, community and mental health settings.” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £250 million to expand same-day and urgent care services and support faster diagnosis, treatment and discharge.
Verbatim wording from the response “• Investing £250 million into expanding same day and urgent care services, helping avoid unnecessary admissions to hospital and supporting faster diagnosis, treatment and discharge for patients.” Source location Response from Department for 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 Improve hospital flow by reducing waits exceeding 12 hours and progressing towards eliminating corridor care.
Verbatim wording from the response “• Improve hospital flow, with a focus on reducing the number of patients waiting more than 12 hours and making progress towards eliminating corridor care.” Source location Response from Department for 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 Introduce clinical operational standards for the first 72 hours of care to support timely review, advice and coordinated care.
Verbatim wording from the response “• Introducing new clinical operational standards for the first 72 hours of care to support better hospital flow. These set minimum expectations for timely review, availability of advice, and coordinated care when multiple specialist teams are involved.” Source location Response from Department for Health and Social Care
Open published response
9 Dec 2025 Urielle Mayila Kuyenga · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Breakdown of communication about responsibility for penicillin prescription and dispensation View source Failure of clinicians to identify Sickle Cell Disease from available clinical records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Urielle Mayila Kuyenga · 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
Urielle Mayila Kuyenga, a four-year-old girl with sickle-cell disease, died in hospital on 4 December 2023 from sepsis resulting from bacterial pneumonia. The report identifies failures to ensure administration of prescribed prophylactic penicillin and failures by doctors to identify her sickle-cell diagnosis during three presentations for respiratory infection as contributory factors.
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 Breakdown of communication about responsibility for penicillin prescription and dispensation
Wider context from the report “1. As a patient with Sickle Cell Disease, Urielle was prescribed prophylactic penicillin to mitigate the risk of her developing fatal symptoms arising from typical respiratory infections. Urielle’s mother chose not to collect those prescriptions and administer penicillin to Urielle. While specialist doctors believed that her GP was monitoring the prescription and dispensation of the penicillin, whilst Urielle’s GP was misled by Urielle’s mother that the hospital were dispensing the medication directly. The breakdown of communication means that Urielle was left unprotected from opportunistic infection which caused this avoidable 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 Failure of clinicians to identify Sickle Cell Disease from available clinical records
Wider context from the report “2. In the weeks prior to her death Urielle’s mother presented her daughter to three separate GPs about a respiratory infection. On each of these three attendances the attending clinician was ignorant of Urielle’s Sickle Cell diagnosis. The reasons for these lapses were, firstly Urielle’s mother did not inform the doctor of the fact and, second, that the doctors did not adequately read the clinical records available to them .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop greater interoperability of electronic patient records, starting with structured medication information sharing.
Verbatim wording from the response “In the absence of an SCP, clear lines of communication should have been established between Urielle’s specialist in the hospital and GP. The overall responsibility for her care, including monitoring and issuing the prescription, should have remained with the hospital. The government is committed to improving this communication between primary and secondary care as outlined in the 10 Year Health Plan in the section on the ‘Red Tape Challenge’ recommendations. These include work to improve information technology through initiatives such as increasing access to shared care records and developing greater interoperability of electronic patient records (EPRs), starting with the sharing of structured medication information.” 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 Implement and jointly publish Jess’s Rule to encourage structured clinical re-evaluation after three unresolved or worsening consultations.
Verbatim wording from the response “To further improve the safety of patients, we have implemented a new initiative in September 2025 called “Jess’s Rule: Three Strikes and Rethink”. This has been published jointly with the Royal College of General Practitioners and NHSE. Under Jess’s Rule, clinicians in general practice are encouraged to take a structured approach to critically re-evaluate symptoms, diagnoses and patient concerns if after three consultations the patient’s condition remains unexpectedly unresolved, their symptoms are escalating and/or they have no clear diagnosis. We know this practice is commonplace in many settings, and GPs, and others use their clinical discretion every day to find the underlying cause of unclear cases.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase access to shared care records to improve communication between primary and secondary care.
Verbatim wording from the response “In the absence of an SCP, clear lines of communication should have been established between Urielle’s specialist in the hospital and GP. The overall responsibility for her care, including monitoring and issuing the prescription, should have remained with the hospital. The government is committed to improving this communication between primary and secondary care as outlined in the 10 Year Health Plan in the section on the ‘Red Tape Challenge’ recommendations. These include work to improve information technology through initiatives such as increasing access to shared care records and developing greater interoperability of electronic patient records (EPRs), starting with the sharing of structured medication information.” 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 Without a shared care protocol, the hospital should retain responsibility for care, monitoring and issuing the prescription.
Verbatim wording from the response “In the absence of an SCP, clear lines of communication should have been established between Urielle’s specialist in the hospital and GP. The overall responsibility for her care, including monitoring and issuing the prescription, should have remained with the hospital. The government is committed to improving this communication between primary and secondary care as outlined in the 10 Year Health Plan in the section on the ‘Red Tape Challenge’ recommendations. These include work to improve information technology through initiatives such as increasing access to shared care records and developing greater interoperability of electronic patient records (EPRs), starting with the sharing of structured medication information.” Source location Response from Department of Health and Social Care
Open published response
9 Dec 2025 Stella Elizabeth LeClaire · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Advocacy of a substance for use in suicide View source Sale of a substance for suicide use View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stella Elizabeth LeClaire · 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
Stella Elizabeth LeClaire was found unresponsive in a Southwark hotel room on 30 July 2023 and was pronounced dead after taking a substance with the intention of ending her life. The report raises concerns about increasing requests for toxicological analysis involving the substance and whether blood toxicology should be obtained routinely in coroners’ investigations concerning poisoning.
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 Advocacy of a substance for use in suicide
Wider context from the report “2. I am also aware that in the last 5 years prevention of future death reports have been submitted from a number of other coroner areas. In broad terms the reasons for those reports are concerns that the substance is sold ████████ advocating its use in suicides ████████ method .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Sale of a substance for suicide use
Wider context from the report “2. I am also aware that in the last 5 years prevention of future death reports have been submitted from a number of other coroner areas. In broad terms the reasons for those reports are concerns that the substance is sold ████████ advocating its use in suicides ████████ method.
” 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 Restrict public access to the substance through targeted operational work with suppliers, platforms and manufacturers, including action against concerning online sales.
Verbatim wording from the response “A significant part of the group’s work has focused on limiting public access to the substance involved in this and other cases, and more than 30 targeted actions have been taken to reduce opportunities to obtain it for non-legitimate purposes. These include operational work with online suppliers, platforms and manufacturers to raise safeguarding concerns, restrict availability, and prevent its sale in particularly concerning ways, including on online forums. Government departments have also worked with online platforms to reduce opportunities for the substance to be purchased by individuals. We are also exploring opportunities to work with Border Force, using existing legal provisions, to improve detection of packages that may be linked to vulnerable individuals.” Source location 2025-0619 - Response from Department of Health and Social Care
Open published response
4 Dec 2025 Lina Piroli · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 9 Failure to provide coordinated care in A&E View source Failure to provide regular clinical reviews in A&E View source Insufficient A&E nursing capacity for patient numbers View source Lack of ward-bed capacity causing delayed transfer of elderly and complex medical patients from A&E View source Delays in access to specialist nurses for patients in A&E View source Failure to provide robust symptom control in A&E View source Failure of A&E environments to provide appropriate care for elderly and complex medical patients View source Failure to provide staff with the expertise required for patients treated in A&E View source Unavailability of geriatric team assessment in A&E View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lina Piroli · 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
Lina Piroli, aged 93, was admitted with an E. coli infection and later suffered an unstable C2 fracture and a stable L1 fracture after a fall down stairs. She remained in A&E for a prolonged period because no elderly care ward bed was available, while experiencing pain, confusion and delirium. The report raises concerns about delayed transfer to a ward and the resulting lack of access to specialist, coordinated care and appropriate symptom management for an elderly, complex patient.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide coordinated care in A&E
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures, regular reviews and coordinated care . She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide regular clinical reviews in A&E
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures, regular reviews and coordinated care. She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of 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 Insufficient A&E nursing capacity for patient numbers
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures, regular reviews and coordinated care. She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of 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 ward-bed capacity causing delayed transfer of elderly and complex medical patients from A&E
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available . This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures, regular reviews and coordinated care. She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of 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 Delays in access to specialist nurses for patients in A&E
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses , robust symptom control measures, regular reviews and coordinated care. She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide robust symptom control in A&E
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures , regular reviews and coordinated care. She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of A&E environments to provide appropriate care for elderly and complex medical patients
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures, regular reviews and coordinated care. She remained in a busy, noisy and frightening environment . It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require . Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide staff with the expertise required for patients treated in A&E
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures, regular reviews and coordinated care. She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise . This means that patients are not receiving the appropriate level of 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 Unavailability of geriatric team assessment in A&E
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures, regular reviews and coordinated care. She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of care.
” 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 bed capacity by reducing average stays for overnight emergency admissions by at least 0.4 days.
Verbatim wording from the response “• Increasing bed capacity by reducing the average length of stay for patients requiring an overnight emergency admission by at least 0.4 days returning closer to pre-pandemic levels.” Source location Response from Department for 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 Embed elderly care expertise throughout urgent and emergency care.
Verbatim wording from the response “Regarding specialist care for the elderly, we recognise that older people are particularly vulnerable to long waits and delayed discharges. We are therefore investing in specialist frailty pathways, expanding the community workforce, and embedding elderly care expertise throughout urgent and emergency care. Initiatives such as frailty Same Day Emergency Care units, rapid front-door frailty team input, and integrated neighbourhood teams are designed to ensure older people receive timely, specialist assessment and support. We are also working to increase the number of geriatricians and frailty specialists, and to strengthen collaboration between hospital and community services, so that discharge planning starts earlier and transitions are safer.” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest in specialist frailty pathways for older people, including frailty same-day emergency care and rapid front-door team input.
Verbatim wording from the response “Regarding specialist care for the elderly, we recognise that older people are particularly vulnerable to long waits and delayed discharges. We are therefore investing in specialist frailty pathways, expanding the community workforce, and embedding elderly care expertise throughout urgent and emergency care. Initiatives such as frailty Same Day Emergency Care units, rapid front-door frailty team input, and integrated neighbourhood teams are designed to ensure older people receive timely, specialist assessment and support. We are also working to increase the number of geriatricians and frailty specialists, and to strengthen collaboration between hospital and community services, so that discharge planning starts earlier and transitions are safer.” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase the number of geriatricians and frailty specialists.
Verbatim wording from the response “Regarding specialist care for the elderly, we recognise that older people are particularly vulnerable to long waits and delayed discharges. We are therefore investing in specialist frailty pathways, expanding the community workforce, and embedding elderly care expertise throughout urgent and emergency care. Initiatives such as frailty Same Day Emergency Care units, rapid front-door frailty team input, and integrated neighbourhood teams are designed to ensure older people receive timely, specialist assessment and support. We are also working to increase the number of geriatricians and frailty specialists, and to strengthen collaboration between hospital and community services, so that discharge planning starts earlier and transitions are safer.” Source location Response from Department for 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 Improve hospital flow by reducing waits exceeding 12 hours and progressing towards eliminating corridor care.
Verbatim wording from the response “• Improve hospital flow, with a focus on reducing the number of patients waiting more than 12 hours and making progress towards eliminating corridor care.” Source location Response from Department for 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 Strengthen collaboration between hospital and community services to support earlier discharge planning and safer transitions.
Verbatim wording from the response “Regarding specialist care for the elderly, we recognise that older people are particularly vulnerable to long waits and delayed discharges. We are therefore investing in specialist frailty pathways, expanding the community workforce, and embedding elderly care expertise throughout urgent and emergency care. Initiatives such as frailty Same Day Emergency Care units, rapid front-door frailty team input, and integrated neighbourhood teams are designed to ensure older people receive timely, specialist assessment and support. We are also working to increase the number of geriatricians and frailty specialists, and to strengthen collaboration between hospital and community services, so that discharge planning starts earlier and transitions are safer.” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £250 million to expand same-day and urgent care services.
Verbatim wording from the response “• Investing £250 million into expanding same day and urgent care services, helping avoid unnecessary admissions to hospital and supporting faster diagnosis, treatment and discharge for patients.” Source location Response from Department for 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 Introduce clinical operational standards for the first 72 hours of hospital care.
Verbatim wording from the response “• Introducing new clinical operational standards for the first 72 hours of care to support better hospital flow. These set minimum expectations for timely review, availability of advice, and coordinated care when multiple specialist teams are involved.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England will respond fully to concerns about A&E waiting times, hospital bed availability, and specialist elderly care.
Verbatim wording from the response “The report raises concerns over A&E waiting times, hospital bed availability, and specialist care for the elderly. In preparing this response, my officials have made enquiries with NHS England and I understand they will be responding to your concerns in full.” Source location Response from Department for Health and Social Care
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations