16 Aug 2019 Justin Peter Gallagher · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 9 Failure to identify and diagnose cancer View source Failure to obtain previous medical history View source Lack of a system for arranging external hospital visits View source Lack of a single clinician responsible for patient care View source Failure to draft proper care plans View source Lack of resources for attending external hospital appointments View source Fragmented responsibility for prison healthcare View source Failure of healthcare organisations to use integrated database systems View source Failure to involve family in obtaining important patient information 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
Justin Peter Gallagher · 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
Justin Peter Gallagher was received at HMP Lewes on 20 March 2016 and was later found collapsed in his segregation-block cell on 24 May 2016. He was taken to hospital, where he died on 17 June 2016; the post-mortem recorded hypoxic brain injury, cardiac arrest and laryngeal carcinoma with upper airway obstruction among the causes. Concerns included the absence of his previous medical history, a proper care plan and a single clinician responsible for his care, cancelled hospital appointments, missed opportunities to diagnose his cancer, lack of family involvement, and separate healthcare organisations using unconnected database systems.
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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 identify and diagnose cancer
Wider context from the report “(3) The deceased died of cancer but this had never been diagnosed and opportunities to have discovered his condition were missed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain previous medical history
Wider context from the report “(1) The prison never obtained his previous medical history. No proper care plan was drafted for him and there was no single clinician responsible for his care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for arranging external hospital visits
Wider context from the report “(2) A number of external hospital appointments were cancelled at short notice because of lack of resources (no available escorts etc.) and there was no system available for arranging such visits .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 single clinician responsible for patient care
Wider context from the report “(1) The prison never obtained his previous medical history. No proper care plan was drafted for him and there was no single clinician responsible for his care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to draft proper care plans
Wider context from the report “(1) The prison never obtained his previous medical history. No proper care plan was drafted for him and there was no single clinician responsible for his care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of resources for attending external hospital appointments
Wider context from the report “(2) A number of external hospital appointments were cancelled at short notice because of lack of resources (no available escorts etc.) and there was no system available for arranging such visits.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Fragmented responsibility for prison healthcare
Wider context from the report “(5) The underlying problem was that healthcare in the prison was the responsibility of three different organisations , namely the prison service, the local mental health NHS Trust (who were given the responsibility of dealing with all physical health matters and running the healthcare centre), and a separate organisation who supplied GPs. These three organisations had entirely separate database systems.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 healthcare organisations to use integrated database systems
Wider context from the report “(5) The underlying problem was that healthcare in the prison was the responsibility of three different organisations, namely the prison service, the local mental health NHS Trust (who were given the responsibility of dealing with all physical health matters and running the healthcare centre), and a separate organisation who supplied GPs. These three organisations had entirely separate database systems.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 involve family in obtaining important patient information
Wider context from the report “(4) There was no involvement of the family and so a source of important information was missed .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the tripartite prison healthcare partnership agreement to add the Department of Health and Social Care and Ministry of Justice for greater oversight and accountability.
Verbatim wording from the response “At a national level, the National Audit Office report into Mental Health in Prisons¹, published in June 2017, made a recommendation in relation to the way that NHS England, Her Majesty’s Prison and Probation Service and Public Health England manage their joint working on prison healthcare.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and operate the National Partnership Agreement for Prison Healthcare 2018–21 as a joined-up framework for collaborative prison healthcare delivery.
Verbatim wording from the response “The National Partnership Agreement for Prison Healthcare in England 2018-21², published in April 2018, acknowledges the need for health and justice partners to work together to ensure “safe, legal, decent and effective care that improves health outcomes for prisoners, reduces health inequalities (particularly for those with protected characteristics), protects the public and reduces reoffending”.” 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 Improve prison healthcare data and intelligence collection and enable information-sharing before, during and after incarceration to support continuity of care.
Verbatim wording from the response “The Agreement sets out a joined-up, strategic approach to meet the complex nature of offender health care needs and provides the partnership members with an overarching framework for collaborative working at all levels. The Agreement has three shared core objectives to be delivered through ten high level priorities. These priorities are underpinned by the Agreement’s 2018 Workplan, which includes a commitment to deliver on three key issues that relate to the responsibilities of all organisations involved in prison care. These commitments are to:” 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 Healthcare providers are responsible for the quality and safety of care provided at HMP Lewes.
Verbatim wording from the response “Providers of healthcare services are responsible for the quality and safety of the care they provide. I expect the healthcare providers at HMP Lewes to look into the care provided to Mr Gallagher and to consider where improvements can be made. This includes how they work with the prison authorities and other relevant organisations, including NHS England which is responsible for commissioning healthcare services for prisoners. Given its role in monitoring, inspecting and regulating the providers of health and social care in prisons, my officials have brought your reports to the attention of the Care Quality Commission (CQC).” Source location Response from Department of Health and Social Care
Open published response
14 Aug 2019 Gladys Esme FURNIVAL (known as Esme FURNIVAL) · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 2 Lack of provision to provide updates to other emergency services during significant ambulance delays View source Lack of provision to utilise other emergency services during significant ambulance delays 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
Gladys Esme FURNIVAL (known as Esme FURNIVAL) · 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
Esme Furnival had an unwitnessed fall at her sheltered accommodation on 8 July 2018 and was suspended by the waist cord of her dressing gown. Although emergency services were called, an ambulance arrived after a significant delay, and the report raised concern that other emergency services were not used to assist when there were no eyes on the ground.
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 provision to provide updates to other emergency services during significant ambulance delays
Wider context from the report “When the ambulance service is faced with significant delays in circumstances where there are no eye’s on the ground, there was no provision to utilise the other emergency services to assist in its place or to provide an update to 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 provision to utilise other emergency services during significant ambulance delays
Wider context from the report “When the ambulance service is faced with significant delays in circumstances where there are no eye’s on the ground, there was no provision to utilise the other emergency services to assist in its place or to provide an update to them.
” Open source report
6 Aug 2019 Joseph Arthur Charles · Prevention of Future Deaths report North London
View report summary
Concerns raised 1 Lack of recommendations or guidance for prevention of DVT and pulmonary embolus in upper limb surgery 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
Joseph Arthur Charles · 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
Joseph Arthur Charles fell at home, underwent right elbow surgery, was discharged, and was later found unresponsive in bed by his wife. The concern was that national guidance existed for preventing deep vein thrombosis and pulmonary embolus after lower-limb surgery but not after upper-limb surgery.
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 recommendations or guidance for prevention of DVT and pulmonary embolus in upper limb surgery
Wider context from the report “That although there are clear National guidelines for the prevention of DVT and pulmonary embolus there are no such recommendations or guidance for upper limb surgery .
” Open source report
1 Aug 2019 Rebecca Louise Henry · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1 Failure to communicate relevant information between mental health care professionals and patients’ close relatives 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
Rebecca Louise Henry · 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
Rebecca Louise Henry attempted to kill herself, was assessed in hospital and discharged as a voluntary patient who was considered not detainable. Later that day, she stood in front of an oncoming train; the principal concern was communication between mental health professionals and close relatives, particularly how confidentiality may limit the sharing of potentially valuable information.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant information between mental health care professionals and patients’ close relatives
Wider context from the report “During almost 40 years sitting as a Coroner, Senior Coroner and now Assistant Coroner, I have heard numerous inquests where had there been communication between the doctors, nurses and therapists caring for patients with mental health issues, and the close relatives of those patients , many issues might have been explained and lives saved.
The reason given in the present case, as in so many others, is that of patient confidentiality.
Whilst the medical authorities are usually right in their interpretation, one wonders whether some form of enquiry/commission might be established to review the law on confidentiality and especially where it interfaces with those patients who have ‘capacity’ but where their relatives have valuable information which could help doctors decide on best care and treatment .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with professional bodies to agree and publish a consensus statement on information sharing and suicide prevention.
Verbatim wording from the response “The Suicide Prevention Strategy for England¹, published in 2012, placed a new emphasis on providing better support to those bereaved or affected by suicide. As part of this, the Department of Health worked with a range of professional bodies to agree a consensus view on confidentiality and suicide prevention. Information sharing and suicide prevention: Consensus statement², was published in 2014, alongside the first annual report of the suicide prevention strategy. The statement includes the following passage:” Source location 2019-0288-Response-by-Department-of-Health-and-Social-Care
Open published response
Concerns raised 2 Insufficient qualified and experienced staffing in Local Authorities serving high proportions of young people in care View source Failure to integrate care, adolescent mental health and education pastoral services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Daniel Cameron SHORROCKS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel Cameron SHORROCKS discussed ending his life with a friend on 1 January 2018, sent a text stating “Dead at Berry Head”, and was found dead at the foot of a cliff at Berry Head. The report’s concerns relate to the availability of qualified and experienced staff for local authorities with many young people in care, and the integration of care, adolescent mental health, and education pastoral 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 Insufficient qualified and experienced staffing in Local Authorities serving high proportions of young people in care
Wider context from the report “(1) I ask please that your Department reviews the availability of resources to those Local Authorities which have a high proportion of young people in care and disproportionately few qualified and experienced 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 Failure to integrate care, adolescent mental health and education pastoral services
Wider context from the report “(2) I would also ask your Department to review the integration of services between Local Authority Care Services, Adolescent Mental Health Services and Pastoral Care provided in education settings .
” Open source report
24 Jul 2019 Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 11 Failure of mental health trusts to communicate placement information with private providers and families View source Failure to consider discharge medication and prescribing risk View source Failure of discharge planning to share risk information with GPs and families View source Failure of private providers to obtain relevant clinical information from referring services View source Failure to provide care coordination after placement with a private provider View source Insufficient mental health training and specialist liaison for university welfare staff View source Failure of universities to identify early signs of anxiety and mental health issues in students View source Lack of alternative mental health provision for young adults View source Lack of suitable acute mental health beds for young adults View source Inadequate guidance on glass balustrade safety where climbable furniture is adjacent View source Failure to communicate the change in risk level when patients leave a secure environment 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
Hannah Dolly Kaur Bharaj · 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
Hannah Dolly Kaur Bharaj had anorexia, depression and fluctuating suicidal ideation, and died at Salford Royal Hospital on 13 July 2018 from injuries sustained after jumping from a first-floor café. Concerns included inadequate communication and discharge planning, unsuitable placement and care coordination, incomplete sharing of clinical information, and the safety of the café balustrade and adjacent table.
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 trusts to communicate placement information with private providers and families
Wider context from the report “4. Communication with private providers by NHS trusts once mental health trusts have placed individuals in private settings. During the time that Hannah was placed at the Priory the mental health trust who placed her did not have any discussion with Hannah, her family or the Priory regarding the placement . A care coordinator had been allocated by the Trust once requested by the Priory but no care coordination had taken place;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to consider discharge medication and prescribing risk
Wider context from the report “2. There was no clear evidence of consideration of discharge medication and risk around prescribing of medication post discharge from the EDU . As a result Hannah was prescribed a month’s supply of medication;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 discharge planning to share risk information with GPs and families
Wider context from the report “1. The inquest heard that discharge planning including communication with GPs and families around risk was not effective . Key information was not shared with the GP or the family particularly when care moved back to the family ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 private providers to obtain relevant clinical information from referring services
Wider context from the report “5.The expectations around information sharing with private providers and the expectation on private providers contracted by the NHS to seek information. The Priory did not request any notes from the EDU about Hannah . As a result they were unaware of detailed information held by the Trust regarding previously expressed suicidal ideation ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 care coordination after placement with a private provider
Wider context from the report “4. Communication with private providers by NHS trusts once mental health trusts have placed individuals in private settings. During the time that Hannah was placed at the Priory the mental health trust who placed her did not have any discussion with Hannah, her family or the Priory regarding the placement. A care coordinator had been allocated by the Trust once requested by the Priory but no care coordination had taken place ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health training and specialist liaison for university welfare staff
Wider context from the report “7. The inquest was told by the clinical lead for Eating Disorders of the high risk of Eating Disorders in high achieving students on courses such as medicine. In such cases, the inquest was told universities need to be alert to early signs of anxiety that risk leading to eating disorders developing. As part of this understanding by universities the inquest was told of the need to recognise early signs of mental health issues and listen carefully from an early stage. The skill set/training of academics in welfare roles in relation to mental health was described as key and specific work with Eating Disorder services and training of those involved in welfare programmes supporting students can be effective ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of universities to identify early signs of anxiety and mental health issues in students
Wider context from the report “7. The inquest was told by the clinical lead for Eating Disorders of the high risk of Eating Disorders in high achieving students on courses such as medicine. In such cases, the inquest was told universities need to be alert to early signs of anxiety that risk leading to eating disorders developing . As part of this understanding by universities the inquest was told of the need to recognise early signs of mental health issues and listen carefully from an early stage . The skill set/training of academics in welfare roles in relation to mental health was described as key and specific work with Eating Disorder services and training of those involved in welfare programmes supporting students can be effective;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of alternative mental health provision for young adults
Wider context from the report “3. The suitability of acute mental health beds for young adults and lack of alternative provision The inquest heard that Hannah went to an acute adult psychiatric bed because the EDU felt that it was the wrong environment for her and there was no other alternative . The inquest heard that there were concerns regarding the placement of a young adult in such a setting and how frightening it was to her;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 suitable acute mental health beds for young adults
Wider context from the report “3. The suitability of acute mental health beds for young adults and lack of alternative provision The inquest heard that Hannah went to an acute adult psychiatric bed because the EDU felt that it was the wrong environment for her and there was no other alternative. The inquest heard that there were concerns regarding the placement of a young adult in such a setting and how frightening it was to her;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate guidance on glass balustrade safety where climbable furniture is adjacent
Wider context from the report “8. The guidance in relation to the height of glass balustrades where items such as tables, in cafes open to the public including children and other vulnerable people, are placed in close proximity to the glass. The glass balustrade in John Lewis was at a height that accorded with the required standard but by simply climbing onto the table that was adjacent to the balustrade Hannah was able to easily go over the balustrade.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the change in risk level when patients leave a secure environment
Wider context from the report “6. Understanding and communication by the Priory about the change in risk level when Hannah moved from a secure environment to periods of time outside the unit in the care of her family;
” Open source report
24 Jul 2019 Xander Curran-Pass · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 10 Lack of guidance on pethidine use with significant reduced fetal movement View source Inconsistent fundal-height measurement and recording View source Lack of national provision for sharing maternity induction-of-labour learning View source Poor quality of admission documentation View source Failure to require obstetrician review on admission with reduced fetal movement and delayed induction of labour View source Lack of clear guidance for managing a prolonged episode of reduced fetal movement View source Inconsistent and unclear diarising, prioritisation and management of induction of labour View source Failure to closely observe a concerning cardiotocograph View source Failure to review cardiotocography after induction of labour commenced View source Failure to advise return to triage for further monitoring during ongoing reduced fetal movement View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Xander Curran-Pass · 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
Xander Curran-Pass was delivered by category C Caesarean Section on 15 September 2018 after reduced fetal movement, delayed induction of labour, and concerning CTG findings. Resuscitation was unsuccessful and he died; post-mortem examination identified poor placental function associated with chronic villitis and thrombotic vasculopathy. The substantive concerns included delays in review and delivery, inadequate monitoring and documentation, and unclear or inconsistent processes for managing induction of labour and reduced fetal movement.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on pethidine use with significant reduced fetal movement
Wider context from the report “6. Xander's mother was given pethidine. There was no guidance on issues to be considered in terms of advisability of pethidine where there was already significant reduced fetal movement ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistent fundal-height measurement and recording
Wider context from the report “5.Xander had his fundal height measured by tape measure by midwives in the community. There was a significant discrepancy between the recorded measurements of two different midwives , which altered where he was on the centile chart significantly ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 provision for sharing maternity induction-of-labour learning
Wider context from the report “1.The inquest was told that there was a growing challenge to maternity units from the rise in Induction of Labour and the pressure to ensure that timescales set out in NICE guidance were met. In this case and since the death of Xander the trust have taken steps to reconfigure their IOL process to reduce risk but no provision to share such learning nationally existed ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor quality of admission documentation
Wider context from the report “7. The quality of documentation on admission was poor ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 obstetrician review on admission with reduced fetal movement and delayed induction of labour
Wider context from the report “4. A review by an obstetrician did not take place on admission despite RFM and delayed IOL . The trust guidance did not require such a review . Such a review may have identified growing concern about condition of Xander;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance for managing a prolonged episode of reduced fetal movement
Wider context from the report “2.In the inquest reference was made to the guidance from the Royal College on reduced fetal movement. The guidance references individual episodes of RFM but does not give clear guidance on the approach to be taken where in effect there is one prolonged episode rather than multiple episodes of RFM ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistent and unclear diarising, prioritisation and management of induction of labour
Wider context from the report “8. The triage and IOL diary were poorly kept and used in different ways by staff . The trust has since changed the way records are kept to ensure consistency and improved its audit process. It is unclear if nationally there is clarity on the way in which IOLs are diarised, prioritised and managed ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to closely observe a concerning cardiotocograph
Wider context from the report “9. The CTG at 07.09 was concerning from the early stages but the evidence suggested that it was not closely observed ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 cardiotocography after induction of labour commenced
Wider context from the report “10. The second CTG after IOL commenced was not reviewed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to advise return to triage for further monitoring during ongoing reduced fetal movement
Wider context from the report “3. Xander's mother was not told it would be advisable to return to triage for further monitoring in light of the ongoing reduced fetal movement. The inquest was told that this would have been advisable given the prolonged nature and the fact that it was unclear when she would be offered a slot for IOL;
” Open source report
15 Jul 2019 Christine Ann Lee and Lucy Daisy Lee · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Absence of a system providing firearms licensing departments with current medical fitness information View source Lack of skills and training for Firearms Enquiry Officers assessing applicants’ medical fitness View source Lack of mandatory comprehensive training for new Firearms Enquiry Officers View source Insufficient gathering of applicants’ relevant medical information before firearms certification decisions View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Christine Ann Lee and Lucy Daisy Lee · 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
Christine Ann Lee and Lucy Daisy Lee, mother and daughter, died after being shot with a shotgun at Keepers Cottage Stud on 23 February 2014. The jury found that failures in Surrey Police’s firearms licensing decisions contributed more than minimally to the deaths. The report also raised concerns about insufficient mandatory training for firearms licensing officers and an unreliable system for assessing applicants’ medical fitness to hold shotgun certificates.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of a system providing firearms licensing departments with current medical fitness information
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application .
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm . These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system: 1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of skills and training for Firearms Enquiry Officers assessing applicants’ medical fitness
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably . I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation .
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system: 1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory comprehensive training for new Firearms Enquiry Officers
Wider context from the report “It was apparent from the evidence that, at the time of the deaths, there was no national training course for staff working in police firearms licensing departments as Firearms Enquiry Officers (“FEOs”) . I was told that work is now being undertaken by the College of Policing to produce an accreditation process for FEOs, but that this work is not yet complete.
Currently, what is known as “the South Yorkshire Training Course” is available. This is a five day, residential course which appears to be comprehensive. I was told that all Surrey Police’s current FEOs have completed the South Yorkshire Training Course, but that it is not mandatory for them to do so.
I am concerned that, pending the introduction of a full accreditation scheme, the absence of a mandatory requirement for all new FEOs (whether in Surrey or elsewhere) to undertake comprehensive training for the role, in the form of the South Yorkshire Training Course or equivalent , will result in the risk of insufficient training, incorrect decision making concerning certification and, consequently, future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient gathering of applicants’ relevant medical information before firearms certification decisions
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant , and the lack of clarity as to what medical conditions may be relevant and must be disclosed , together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness .
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system: 1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Open source report
15 Jul 2019 Christine Ann Lee and Lucy Daisy Lee · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Absence of mandatory comprehensive training for Firearms Enquiry Officers View source Lack of relevant training and competence among Firearms Enquiry Officers assessing medical fitness View source Absence of ongoing notification of relevant medical changes during firearms certificate validity View source Insufficient medical-condition disclosure and evidence gathering before firearms licensing decisions View source Absence of a required current GP medical report before firearms certificate applications View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Christine Ann Lee and Lucy Daisy Lee · 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
Christine Ann Lee and Lucy Daisy Lee, mother and daughter, died after being shot with a shotgun at Keepers Cottage Stud on 23 February 2014. The report identified failures by Surrey Police firearms licensing staff to sufficiently investigate and consider relevant information, apply the correct standard of proof, and ensure appropriate senior oversight before returning the perpetrator’s shotgun certificate and shotguns. It also raised concerns about insufficient mandatory training for firearms enquiry officers and an unreliable system for assessing applicants’ medical fitness to hold shotgun certificates.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of mandatory comprehensive training for Firearms Enquiry Officers
Wider context from the report “It was apparent from the evidence that, at the time of the deaths, there was no national training course for staff working in police firearms licensing departments as Firearms Enquiry Officers (“FEOs”) . I was told that work is now being undertaken by the College of Policing to produce an accreditation process for FEOs, but that this work is not yet complete.
Currently, what is known as “the South Yorkshire Training Course” is available. This is a five day, residential course which appears to be comprehensive. I was told that all Surrey Police’s current FEOs have completed the South Yorkshire Training Course, but that it is not mandatory for them to do so .
I am concerned that, pending the introduction of a full accreditation scheme, the absence of a mandatory requirement for all new FEOs (whether in Surrey or elsewhere) to undertake comprehensive training for the role , in the form of the South Yorkshire Training Course or equivalent, will result in the risk of insufficient training, incorrect decision making concerning certification and, consequently, future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of relevant training and competence among Firearms Enquiry Officers assessing medical fitness
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably . I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation .
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system:
1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of ongoing notification of relevant medical changes during firearms certificate validity
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system:
1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes .”
I understand that this recommendation has not been implemented . This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient medical-condition disclosure and evidence gathering before firearms licensing decisions
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant , and the lack of clarity as to what medical conditions may be relevant and must be disclosed , together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness .
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system:
1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of a required current GP medical report before firearms certificate applications
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system:
1. Does not allow licensing to take place without a current medical report from the applicant’s GP , obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate , and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented . This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Open source report
28 Jun 2019 Heather Birchall · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 2 Failure to provide healthcare professionals with complete relevant mental-health information for frontline assessments View source Failure to share relevant mental-health information between healthcare practitioners and patients’ families 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
Heather Birchall · 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
Heather Birchall, who was homeless and had mental health problems and alcohol dependence, died after consuming excess amounts of medication alongside alcohol; bronchopneumonia also contributed to the mechanism of death. The principal concern was that healthcare professionals assessing people in police custody might lack relevant mental health information because of confidentiality barriers, potentially limiting informed decisions about further care and safeguarding life.
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 healthcare professionals with complete relevant mental-health information for frontline assessments
Wider context from the report “One of the concerns that arose relates to G4S healthcare professionals and any other healthcare professional in this situation when asked to carry out a front line assessment which could include mental health features, that those individuals may not have the fullest amount of information that is available so that they can make an informed decision as to whether or not for example further healthcare input is required , such as an example a formal mental health at assessment. Whilst a problem insofar as getting a complete picture did not seem to be quite such an issue when personnel from LADS were available it would appear that out of those hours, if a G4S healthcare professional wanted to make enquiries insofar as an individual’s mental health background which potentially might be within the knowledge of the relevant healthcare trust, that when an approach is made to the Street Triage team out of hours that more often than not the issue of confidentiality was raised to withhold information or I felt that equally there was a danger that selective information might only be passed at best to the G4S healthcare operative . The concern that I was left with was that the healthcare professionals from G4S and arguably at the end of the day Wiltshire Police who ultimately responsibility it is to safeguard life when an individual is in Police custody are effectively trying to do a job, through their contract service providers (G4S), in circumstances whereby in trying to discharge their duty having regard to Article 2 of European Convention of Human Rights they were doing so effectively, as a consequence of patient confidentiality, with one arm tied behind their back.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant mental-health information between healthcare practitioners and patients’ families
Wider context from the report “It is my view in relation to other hearings that confidentiality can equally pose a problem insofar as communications between healthcare practitioners on the mental health side and a patient’s family . Either of which may have relevant information that would have been of benefit to the other and in respect of which could prevent the loss of life through self-harm and suicide . Whilst the issue of confidentiality should be respected I am concerned that consideration needs to be given to redressing and practical exceptions to that general principle especially if the aim is with a view to safeguarding life.
” Open source report
24 Jun 2019 Lewis James Doyle · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2 Failure to send discharge letters to all current medical attendants View source Failure to provide original prescribers with information about suspended or stopped medication 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
Lewis James Doyle · 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
Lewis James Doyle, who had multiple medical conditions including coronary artery disease and recurrent depressive illness, died on 8 January 2019 after developing worsening respiratory illness and pulmonary oedema following traumatic injuries sustained when he fell in front of a train. The principal concern was that discharge letters, including information about suspended or stopped medication, should be sent to all current medical attendants across primary, secondary and tertiary care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to send discharge letters to all current medical attendants
Wider context from the report “When Mr Doyle was discharged from the Liverpool Heart and Chest Hospital the GP discharge letter was sent to his GP. Mr GP Doyle was receiving treatment for Acute Coronary Syndrome but also mental health care for a Recurrent Depressive Illness (without Psychosis). Lithium had to be stopped not only because it was at a toxic level but also because of the effect of this and alternate medications on cardiac health. It occurred during the inquest that in similar scenarios better patient care could be delivered, if discharge letters were sent to all current medical attendants, whether in primary, secondary or tertiary care. Information with regarded to suspended or stopped medication was needed by the original prescribers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 original prescribers with information about suspended or stopped medication
Wider context from the report “When Mr Doyle was discharged from the Liverpool Heart and Chest Hospital the GP discharge letter was sent to his GP. Mr GP Doyle was receiving treatment for Acute Coronary Syndrome but also mental health care for a Recurrent Depressive Illness (without Psychosis). Lithium had to be stopped not only because it was at a toxic level but also because of the effect of this and alternate medications on cardiac health. It occurred during the inquest that in similar scenarios better patient care could be delivered, if discharge letters were sent to all current medical attendants, whether in primary, secondary or tertiary care. Information with regarded to suspended or stopped medication was needed by the original prescribers.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing legal and professional duties provide a sufficient framework for information sharing, so further data-sharing requirements are unnecessary.
Verbatim wording from the response “I am advised that these legal and professional duties provide a clear framework for the effective sharing of information to support the care and treatment of patients, enabling medical professionals to make decisions on a case by case basis about the information that should be shared.” Source location 2019-0214-Response-by-Department-of-Health-and-Social-care
Open published response
19 Jun 2019 Mason Logue · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Lack of understanding among community health practitioners about the use and importance of Early Health Assessments View source Lack of a single IT system supporting information sharing across NHS trusts View source Failure of health professionals to understand and use the red book for information sharing View source Lack of shared understanding of information dissemination roles and responsibilities View source Failure of health and social care services to provide integrated care and share health information View source Lack of an overarching supportive care plan on discharge View source Failure to allocate a health professional to oversee and coordinate care for children with multiple specialist needs View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mason Logue · 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
Mason Logue, who had been born prematurely and had a complex medical history, was found unresponsive in his mother’s bed at home on 28 October 2017. The post-mortem examination did not identify a clear cause of death, and the medical cause was recorded as unascertained. Concerns included limited integration and information sharing between services, the absence of an overarching supportive care plan and a single professional coordinating his care, and difficulties arising from differing protocols and the lack of a single IT system across NHS trusts.
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 understanding among community health practitioners about the use and importance of Early Health Assessments
Wider context from the report “There was a lack of understanding about the use and importance of Early Health Assessments amongst community health practitioners .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 single IT system supporting information sharing across NHS trusts
Wider context from the report “The inquest heard evidence that the lack of a single IT system across NHS trusts meant that information sharing was more difficult . The red book was not utilised as a tool for sharing information other than by the Health Visitor to record standard information e.g. weight. The purpose and value of the red book was unclear amongst the health professionals. It was clear that clinicians in hospitals rarely utilised it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of health professionals to understand and use the red book for information sharing
Wider context from the report “The inquest heard evidence that the lack of a single IT system across NHS trusts meant that information sharing was more difficult. The red book was not utilised as a tool for sharing information other than by the Health Visitor to record standard information e.g. weight. The purpose and value of the red book was unclear amongst the health professionals. It was clear that clinicians in hospitals rarely utilised it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of shared understanding of information dissemination roles and responsibilities
Wider context from the report “During the course of the inquest, it was clear that the understanding of local health professionals about how information would be disseminated in accordance with MOUs and protocols was different from the tertiary centre . This meant that there were different views held between health professionals as to their roles and responsibilities .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of health and social care services to provide integrated care and share health information
Wider context from the report “The inquest heard that Mason was discharged directly from the tertiary centre into the community after a prolonged period of care in NICU. His mother had previously been known to Family Services. There was limited evidence available of an integrated approach to care from the Local Authority, Tertiary Centre, Local Hospital and Community Health Professionals. As a result, information about his health was not shared between all health professionals . There was no overarching supportive care plan in place on discharge.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of an overarching supportive care plan on discharge
Wider context from the report “The inquest heard that Mason was discharged directly from the tertiary centre into the community after a prolonged period of care in NICU. His mother had previously been known to Family Services. There was limited evidence available of an integrated approach to care from the Local Authority, Tertiary Centre, Local Hospital and Community Health Professionals. As a result, information about his health was not shared between all health professionals. There was no overarching supportive care plan in place on discharge.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 allocate a health professional to oversee and coordinate care for children with multiple specialist needs
Wider context from the report “Furthermore, no one health professional had an overview of his health needs and ensuring that support was put in place and appointments were coordinated . There was no system for an allocated paediatrician to coordinate care where multiple paediatric specialists were involved.
” Open source report
3 Jun 2019 Mr Matthew Jones · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 4 Lack of appropriate training for clinicians and healthcare workers responsible for persons subject to Community Mental Health Treatment Orders View source Failure to include housing in hospital discharge planning View source Poor appreciation of the likely risks of non-compliance with treatment linked to Community Mental Health Treatment Orders View source Lack of co-ordinated and multi-agency working in care for persons subject to Community Mental Health Treatment Orders 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
Mr Matthew Jones · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Matthew Jones, who had paranoid schizophrenia and polysubstance misuse, was discharged from hospital to minimally supported temporary accommodation and suffered a cardiac arrest shortly afterwards; his death was attributed to cocaine toxicity. The report identified concerns about inadequate training and poor coordinated, multi-agency working, including insufficient attention to housing in hospital discharge planning.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate training for clinicians and healthcare workers responsible for persons subject to Community Mental Health Treatment Orders
Wider context from the report “The evidence at the Inquest, the evidence revealed:
(i) an absence of appropriate training for clinicians and healthcare workers involved in the delivery of mental health services who have responsibility for the care of persons subject to Community Mental Health Treatment Orders (linked to Mental Health Treatment Requirement Care-Plans including treatment by Drug & Alcohol Services) ; and, as a result,
(ii) a poor appreciation, including a lack of co-ordinated and multi-agency working, by such clinicians and healthcare workers of the likely risks of non-compliance with treatment linked to Community Mental Health Treatment Orders, and, particularly, of the importance of ensuring that ‘housing’ is part of any hospital discharge planning.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 include housing in hospital discharge planning
Wider context from the report “The evidence at the Inquest, the evidence revealed:
(i) an absence of appropriate training for clinicians and healthcare workers involved in the delivery of mental health services who have responsibility for the care of persons subject to Community Mental Health Treatment Orders (linked to Mental Health Treatment Requirement Care-Plans including treatment by Drug & Alcohol Services); and, as a result,
(ii) a poor appreciation, including a lack of co-ordinated and multi-agency working, by such clinicians and healthcare workers of the likely risks of non-compliance with treatment linked to Community Mental Health Treatment Orders, and, particularly, of the importance of ensuring that ‘housing’ is part of any hospital discharge planning .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor appreciation of the likely risks of non-compliance with treatment linked to Community Mental Health Treatment Orders
Wider context from the report “The evidence at the Inquest, the evidence revealed:
(i) an absence of appropriate training for clinicians and healthcare workers involved in the delivery of mental health services who have responsibility for the care of persons subject to Community Mental Health Treatment Orders (linked to Mental Health Treatment Requirement Care-Plans including treatment by Drug & Alcohol Services); and, as a result,
(ii) a poor appreciation , including a lack of co-ordinated and multi-agency working, by such clinicians and healthcare workers of the likely risks of non-compliance with treatment linked to Community Mental Health Treatment Orders , and, particularly, of the importance of ensuring that ‘housing’ is part of any hospital discharge planning.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 co-ordinated and multi-agency working in care for persons subject to Community Mental Health Treatment Orders
Wider context from the report “The evidence at the Inquest, the evidence revealed:
(i) an absence of appropriate training for clinicians and healthcare workers involved in the delivery of mental health services who have responsibility for the care of persons subject to Community Mental Health Treatment Orders (linked to Mental Health Treatment Requirement Care-Plans including treatment by Drug & Alcohol Services); and, as a result,
(ii) a poor appreciation, including a lack of co-ordinated and multi-agency working , by such clinicians and healthcare workers of the likely risks of non-compliance with treatment linked to Community Mental Health Treatment Orders, and, particularly, of the importance of ensuring that ‘housing’ is part of any hospital discharge planning.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The local NHS is responsible for reviewing the case circumstances and taking necessary action to ensure services are safe and high quality.
Verbatim wording from the response “Organisations commissioning and delivering services are expected to take the recommendations within NICE clinical guidelines into account when planning and delivering services. We expect the local NHS to look closely at the circumstances of this case and to take action where necessary to ensure services are safe and of high quality.” Source location 2019-0187-Response-by-Department-of-Health-and-Social-Care
Open published response
23 May 2019 Sasha Sabrina FORSTER · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 6 Risk of using prescribed Propranolol for overdose View source Failure to agree and update a common action plan for revoked s.17 leave View source Failure to collect and return patients to the ward when s.17 leave is revoked View source Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol View source Failure to finalise the formal revocation of s.17 leave View source Lack of shared awareness of powers and responsibilities when s.17 leave is revoked 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
Sasha Sabrina FORSTER · 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
Sasha Sabrina FORSTER, a 20-year-old woman with a lengthy history of mental health disorders, self-harm and overdoses, died by suicide following deliberate ingestion of a fatal overdose of Propranolol tablets. The inquest identified concerns that hospitals and police forces were not always aware of their powers and responsibilities when her section 17 leave was revoked, or had not agreed and updated a common plan, resulting in inconsistent actions and an increased risk to Sasha.
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 of using prescribed Propranolol for overdose
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to agree and update a common action plan for revoked s.17 leave
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked, or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances .
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to collect and return patients to the ward when s.17 leave is revoked
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked , was that they did not have the resources to allow them to do this , despite it being their legal responsibility so to do .
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked , placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised, Sasha’s mother was given to believe that it would be, and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to finalise the formal revocation of s.17 leave
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked, was that they did not have the resources to allow them to do this, despite it being their legal responsibility so to do.
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked, placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised , Sasha’s mother was given to believe that it would be , and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 shared awareness of powers and responsibilities when s.17 leave is revoked
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked , or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances.
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Care providers have no legal responsibility to arrange return of patients whose section 17 leave is revoked.
Verbatim wording from the response “In relation to leave of absence from hospital, you may wish to note that the Department does not agree that care providers have a legal responsibility to arrange for the return to hospital of patients whose section 17 leave has been revoked.” Source location Sasha-Forster-R2019-0169
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 GMC prescribing guidance, when followed, is considered sufficient to ensure safe practice and protect patient safety.
Verbatim wording from the response “Turning to the matter of concern relating to the prescribing of propranolol. My officials have made enquiries and I am aware that the General Medical Council (GMC) has responded to you to explain that its prescribing guidance² is clear that a doctor must only prescribe when they have adequate knowledge of the patient’s health. This should involve making an assessment together with the patient of their condition and having, or taking, an adequate history. A patient’s consent to contact their GP should be sought if more information, or confirmation of the information available, is needed before prescribing. The GMC is confident that its guidance, when followed, ensures safe practice and protects patient safety.” Source location Sasha-Forster-R2019-0169
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 Care providers decide how to facilitate returns after revoked section 17 leave, using resources available to them.
Verbatim wording from the response “Section 18 of the Mental Health Act gives hospitals the power to take a patient into custody for return to the hospital or place of treatment. However, it does not place a legal responsibility on hospitals to arrange this. As such, it is for care providers to decide on the best way to facilitate such returns from within the resources available to them.” Source location Sasha-Forster-R2019-0169
Open published response
16 May 2019 Natasha Elizabeth Victoria Abrahart · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Failure to arrange timely follow-up review after starting antidepressants for people at increased suicide risk or younger than 30 years 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
Natasha Elizabeth Victoria Abrahart · 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
Natasha Elizabeth Victoria Abrahart died on 30 April 2018 after placing a ligature around her neck. She was under the care of a mental health team that had not provided a timely and detailed management plan following several assessments. The report also identifies concerns that follow-up after starting sertraline, including review of suicide risk, did not comply with the cited NICE guideline; the inquest concluded that the death was suicide contributed to by neglect.
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 arrange timely follow-up review after starting antidepressants for people at increased suicide risk or younger than 30 years
Wider context from the report “The NICE guideline Depression in Adults: Recognition and management (CG90) states in section 1.5.2.7 “A person with depression started on antidepressants who is considered to present an increased suicide risk or is younger than 30 years (because of the potential increased prevalence of suicidal thoughts in the early stages of antidepressant treatment for this group) should normally be seen after 1 week and frequently thereafter as appropriate until the risk is no longer considered clinically important ”
In this case Sertraline was prescribed but the NICE guideline was not followed by the mental health trust or the GP practice.
The expert indicated that the review at 1 week is to ensure that the patient is taking the medication, to check for any side effects including suicide risk and to see what has happened ; that review can be done by the G.P. or the mental health team but there needs to be a known appointment.
” Open source report
10 May 2019 Karanbir Singh CHEEMA · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 12 Failure to transmit allergy action plans to schools View source Lack of standardisation of allergy action plans across hospitals and schools View source Omission of second adrenaline auto-injector guidance from the emergency call algorithm View source Failure to ensure that school medication is in date View source Lack of awareness that a second adrenaline auto-injector should be administered after deterioration or non-improvement View source Delays in time-critical asthma and allergy review appointments View source Lack of school pupil understanding of allergies and the consequences of allergen exposure View source Failure to check or audit school allergy care plans and medication boxes View source Lack of awareness that adrenaline should be administered immediately for respiratory compromise after allergen exposure View source Insufficient availability of two adrenaline auto-injectors at all times View source Failure to communicate emergency adrenaline instructions effectively in school staff training View source Absence of emergency adrenaline instructions on EpiPen packaging View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Karanbir Singh CHEEMA · 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
Karanbir Singh CHEEMA, a pupil at William Perkin High School with multiple food allergies and asthma, went into anaphylactic shock after another pupil threw cheese at him on 28 June 2017 and died. Concerns included inadequate awareness of his allergies, insufficient checking and availability of EpiPens, an out-of-date EpiPen, failures in sharing and standardising allergy action plans, a cancelled follow-up appointment, and shortcomings in emergency response guidance and training.
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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 transmit allergy action plans to schools
Wider context from the report “5. The allergy action plan drafted by Karanbir’s doctors at Ealing Hospital did not find its way to his school . There is no standardised approach to this , for example always sending a copy to the school designated safeguarding lead, as well as giving parents/carers a copy for themselves and a copy for the school in case the posted version does not arrive.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 standardisation of allergy action plans across hospitals and schools
Wider context from the report “4. Allergy action plans are not standardised across hospitals and schools , so messages are not as clearly delivered as they could be . This is vital particularly when they may be read for the first time in a desperate situation where panic has set in.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Omission of second adrenaline auto-injector guidance from the emergency call algorithm
Wider context from the report “11. The London Ambulance Service 999 operator did not at any time suggest that a second EpiPen be given , because this is not contained within the algorithm . That could be remedied internationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that school medication is in date
Wider context from the report “3. Karanbir’s EpiPen was out of date . There must be systems in place to ensure that medication in schools is in date .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness that a second adrenaline auto-injector should be administered after deterioration or non-improvement
Wider context from the report “8. There appears to be a lack of awareness nationally of the simple but vital messages that:
- if a person with an allergy has been exposed to an allergen and develops any respiratory compromise, so any breathing difficulty at all, then adrenaline (via EpiPen or other) should be administered immediately, before any asthma pump and even before calling for help;
- if there is a deterioration after giving one EpiPen, then another should be administered immediately, or in any event after five minutes if there is no 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 time-critical asthma and allergy review appointments
Wider context from the report “6. Karanbir’s treating doctors wanted him to re-attend for asthma and allergy review four months after his last consultation. An appointment was made but cancelled by the hospital . By the time of his death four months later he had still not been seen again . There needed to be recognition of the time critical nature of this appointment. It needed to be re-booked without delay.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 school pupil understanding of allergies and the consequences of allergen exposure
Wider context from the report “1. The pupils at Karanbir’s school had a patchy understanding of his allergies, what they were and the consequences of exposure to allergens . Targeted education about this would improve safety.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to check or audit school allergy care plans and medication boxes
Wider context from the report “2. Karanbir’s school care plan and medical box were not checked or audited to ensure, for example, that his care plan stipulated two EpiPens® (adrenaline auto-injectors), the box contained two EpiPens.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness that adrenaline should be administered immediately for respiratory compromise after allergen exposure
Wider context from the report “8. There appears to be a lack of awareness nationally of the simple but vital messages that:
- if a person with an allergy has been exposed to an allergen and develops any respiratory compromise, so any breathing difficulty at all, then adrenaline (via EpiPen or other) should be administered immediately , before any asthma pump and even before calling for help;
- if there is a deterioration after giving one EpiPen, then another should be administered immediately, or in any event after five minutes if there is no 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 Insufficient availability of two adrenaline auto-injectors at all times
Wider context from the report “7. Karanbir had one EpiPen at home, one at school and one at his father’s home . There is clearly a need for medical teams to emphasise that two EpiPens must be available at all times .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 emergency adrenaline instructions effectively in school staff training
Wider context from the report “10. These instructions were not communicated effectively as part of the school staff’s first aid and EpiPen training .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 emergency adrenaline instructions on EpiPen packaging
Wider context from the report “9. The EpiPen box does not contain these instructions on the outside .
” Open source report
2 May 2019 Benjamin James Charles MURRAY · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure to ensure that mental health disclosure is de-stigmatised and does not deter university admission View source Lack of post-death investigation reports for student deaths View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Benjamin James Charles MURRAY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 5 May 2018, Ben was found beneath the Clifton suspension bridge after walking onto the bridge, climbing onto the buttress wall and propelling himself forward. The inquest concluded that his death was suicide. The report raised concerns about mental health disclosure by university applicants, the pastoral role of universities during transition to higher education, and the absence of university investigation reports following a student death.
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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 ensure that mental health disclosure is de-stigmatised and does not deter university admission
Wider context from the report “2. For UCAS, The Department of Education and The Minister for Suicide Prevention
The concern over mental health disclosure either on the UCAS application form or indeed to a prospective University.
I am told that currently such disclosure is at 37%. There needs to be a move towards de-stigmatising mental health and ensuring that students are made aware that by disclosing mental health problems on their UCAS form or to their prospective University that it will not affect getting a place at University.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of post-death investigation reports for student deaths
Wider context from the report “3. For Bristol University, The Department of Education and The Minister for Suicide Prevention
The transition from home to University can be a challenging time for some students and Universities clearly have the primary role of education however this inquest has demonstrated they also carry out an important pastoral role.
It is not the role of the Coroner to investigate Ben’s journey through University in light of the circumstances of his tragic death and the limited scope. That said as a Coroner has a duty to consider prevention of future deaths it was appropriate in this case that aspects of Ben’s progress were investigated by me.
In addition currently the University sector does not carry out an investigation report (such as a root cause analysis or sudden untoward investigation) after a death of a student. Such a written report usually affords an opportunity to review what happened; what was done well/the good practice points; areas of concern, if there are any, and importantly what lessons can be learned often with a formal written action plan. Such a document is also very helpful to the Coroner when considering and discharging this duty. Such a formal process and document most importantly assists in preventing future deaths.
” Open source report
27 Mar 2019 Ms Donna Williamson · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Failure to assign responsibility for repairing and securing doors in privately rented accommodation View source Failure to inform victims promptly when suspects are released on bail View source Insufficient clarity and knowledge of professional and legal duties to disclose confidential information about victims at risk View source Failure to contact available support services for disabled private tenants View source Failure of the MARAC process to provide coordinated protection and support for chaotic non-engaging individuals View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Ms Donna Williamson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Donna Williamson, a 44-year-old woman with mental health, alcohol dependence, mobility and domestic abuse vulnerabilities, died from stab wounds to the chest after being assaulted with a knife by her ex-partner. The principal concerns included the failure to secure her insecure door, failure to inform her that the suspect had been released on bail, and weaknesses in the MARAC process for protecting chaotic and non-engaging individuals.
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 assign responsibility for repairing and securing doors in privately rented accommodation
Wider context from the report “1. No one agency took responsibility for repairing and securing the door. The detailed evidence is attached in an Appendix. Additionally a local authority officer gave evidence that the local authority did not realize that they had a duty to repair it if the landlord did not . Additionally it was reported that there was a local scheme that provided a service for disabled people which was not contacted. Local authorities may need wider awareness of how to resolve such problems for privately renting vulnerable tenants.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to inform victims promptly when suspects are released on bail
Wider context from the report “2. There was a failure to inform the victim that the suspect had been released on bail. Whilst the Metropolitan Police Service have taken steps to address this risk, wider awareness amongst other police forces of the importance of this being completed in a timely manner may be of value.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 clarity and knowledge of professional and legal duties to disclose confidential information about victims at risk
Wider context from the report “4. Key information about the risk to the victim was secured by the police from the suspect’s GP, who has commendably established new procedures for handling domestic abuse, but the GP was unable to articulate what were the criteria when a GP has a duty to disclose confidential information to the police in relation to a victim at risk. There is a risk that GPs in general may not have sufficient knowledge or awareness of their professional and legal duties of disclosure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 contact available support services for disabled private tenants
Wider context from the report “1. No one agency took responsibility for repairing and securing the door. The detailed evidence is attached in an Appendix. Additionally a local authority officer gave evidence that the local authority did not realize that they had a duty to repair it if the landlord did not. Additionally it was reported that there was a local scheme that provided a service for disabled people which was not contacted . Local authorities may need wider awareness of how to resolve such problems for privately renting vulnerable tenants.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 MARAC process to provide coordinated protection and support for chaotic non-engaging individuals
Wider context from the report “3. The MARAC process was incapable of facilitating protection and resolution of problems for chaotic non engaging individuals. Lengthy evidence was heard from the independent chair of the Domestic Homicide Review, who had conducted 23 such reviews. She said that the MARAC system can be good depending on the priority given by each organization. In this case agencies should have worked together to address risks in the context of her life environment and network. Instead her needs were compartmentalised. Her evidence was clear that no MARAC can deliver the needs of chaotic non engaging individuals . She reported that there were arguments for MARAC and other bodies to be put on a statutory footing. Clearly there is an urgent need for national review how the system can afford protection and support for these particularly vulnerable complex individuals or whether changes need to be made to it.
” Open source report
19 Mar 2019 Mohammed Shabol AHMED · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 2 Failure to establish whether information about olanzapine-associated drug reaction with eosinophilia and systemic symptoms is known to clinicians nationally View source Risk of adverse allergic reactions and drug reaction with eosinophilia and systemic symptoms from combined Spice use and olanzapine exposure 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
Mohammed Shabol AHMED · 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
Mohammed Shabol Ahmed, a long-term illicit drug user with schizophrenia and a learning disability, was found deceased in his prison cell the morning after being returned from hospital following a drug-related collapse. Concerns included the possible interaction between olanzapine and Spice, failures in information-sharing between the prison, healthcare and hospital, and inadequate prison training for drug-related incidents and their aftermath.
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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 establish whether information about olanzapine-associated drug reaction with eosinophilia and systemic symptoms is known to clinicians nationally
Wider context from the report “(1) The expert evidence of ████████ (Emeritus of Forensic Medicine) gave evidence that the use of Spice can prime a person for an allergic reaction. In the case of Mr Ahmed Olanzapine and Spice combined to cause an adverse allergic reaction. He had been prescribed Olanzapine throughout his imprisonment in the knowledge of Spice use.
(2) Healthcare records demonstrated that his eosinophilia count was recorded as reduced following a change in medication from Olanzapine to Risperidone.
(3) The expert evidence was that it was a very rare side effect but one which the U.S. Food and Drug Administration has warned that drug reaction with eosinophilia and systemic symptoms has been reported with olanzapine exposure.
(4) The jury was not able to find that the death was caused or contributed to by the use of Spice. It remains unclear whether the expert opinion is one which is or should be made known to clinicians nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Risk of adverse allergic reactions and drug reaction with eosinophilia and systemic symptoms from combined Spice use and olanzapine exposure
Wider context from the report “(1) The expert evidence of ████████ (Emeritus of Forensic Medicine) gave evidence that the use of Spice can prime a person for an allergic reaction. In the case of Mr Ahmed Olanzapine and Spice combined to cause an adverse allergic reaction. He had been prescribed Olanzapine throughout his imprisonment in the knowledge of Spice use.
(2) Healthcare records demonstrated that his eosinophilia count was recorded as reduced following a change in medication from Olanzapine to Risperidone.
(3) The expert evidence was that it was a very rare side effect but one which the U.S. Food and Drug Administration has warned that drug reaction with eosinophilia and systemic symptoms has been reported with olanzapine exposure.
(4) The jury was not able to find that the death was caused or contributed to by the use of Spice. It remains unclear whether the expert opinion is one which is or should be made known to clinicians nationally.
” 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 Current olanzapine warnings adequately address the identified risks, so no further regulatory action is considered necessary at this time.
Verbatim wording from the response “I am advised by the MHRA that it considers the current warnings on the Summary of Product Characteristics (SPC) for olanzapine about adverse drug reactions of eosinophilia, and of drug reaction with eosinophilia and systemic symptoms with olanzapine appropriately address the nature of these risks, and given the absence of similar reported cases, does not intend to take further regulatory action at this time.” Source location 2019-0093-Response-by-Department-of-Health
Open published response
26 Feb 2019 Mr Nathan Mooney · Prevention of Future Deaths report Manchester South
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Concerns raised 1 Significant reliance on locum doctors to cover clinical shifts View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr Nathan Mooney · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Nathan Mooney died on 23 May 2017 after developing severe abdominal pain and later collapsing at home. He had previously undergone a splenectomy in which an iatrogenic diaphragmatic defect was repaired; a post-mortem examination determined that he died following colonic herniation and perforation associated with a diaphragmatic defect. The principal concern was Tameside General Hospital’s heavy reliance on locum doctors, with potential adverse effects on continuity of care and effective relationships between clinical teams.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Significant reliance on locum doctors to cover clinical shifts
Wider context from the report “It is apparent that at the time of Mr Mooney’s care, Tameside General Hospital was heavily reliant on locum doctors to cover shifts .
The court heard evidence of measures which have been taken locally to recruit and retain doctors to substantive posts, however significant reliance on locum doctors remains an issue . The court heard evidence from one of the Trust’s Clinical Directors that this resulted from a lack of suitably skilled doctors in the UK labour market which in turn was compounded by a high attrition rate across a number of specialties whereby doctors do not complete their post graduate speciality training within the NHS (choosing instead, for example, to work overseas).
In addition to the obvious financial consequences of significant locum use for the NHS, the court heard that it can impact adversely upon continuity of care, and militate against development of established and effective relationships between clinical teams.
The Clinical Director expressed the view that the current position would be alleviated to a certain extent by implementation of a system whereby graduates of UK medical schools were (no doubt in consideration for financial or other support during training) tied-in to a specified period of NHS work following graduation. Whilst the Clinical Director was aware of previous discussions within the NHS about such a system, she was not aware of any plans to implement such a system.
It is noted the previous Senior Coroner for this Area, John Pollard, had an exchange of correspondence with the former Under Secretary for Care Quality, Ben Gummer MP, in 2016 in which similar issues were raised.
” 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 Set out through the workforce implementation plan how to achieve the NHS Long Term Plan’s workforce framework over the next ten years.
Verbatim wording from the response “The workforce implementation plan will set out how we can achieve the strategic framework set out in the NHS Long Term Plan, published in January 2019, to ensure that over the next ten years the NHS will have the staff it needs so that the NHS workforce has the time it needs to care, working in a supportive culture that allows them to provide the expert compassionate care they are committed to providing.” Source location 2019-0072-Responses
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 Undertake detailed follow-up work on return-of-service arrangements after the consultation.
Verbatim wording from the response “With regard to tie-in, as part of expanding undergraduate medical education, the Government ran a consultation in 2017 and asked specific questions about the concept of return of service for doctors. The feedback from this consultation set out some complex issues and Health Education England (HEE) undertook further detailed work, which now needs to be considered as part of the HEE Enhancing Junior Doctors’ Working Lives programme and the workforce implementation plan.” Source location 2019-0072-Responses
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a workforce implementation plan covering required staff and skills, workforce growth, supportive culture and NHS leadership.
Verbatim wording from the response “The workforce implementation plan, commissioned by the Secretary of State, is led by Baroness Dido Harding, Chair of NHS Improvement, working closely with Sir David Behan, Chair of Health Education England. The plan will consider the additional staff and skills required and include proposals to grow the workforce; build a supportive working culture in the NHS; and to ensure first rate leadership for NHS staff.” Source location 2019-0072-Responses
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider return-of-service work within the Enhancing Junior Doctors’ Working Lives programme and workforce implementation plan.
Verbatim wording from the response “With regard to tie-in, as part of expanding undergraduate medical education, the Government ran a consultation in 2017 and asked specific questions about the concept of return of service for doctors. The feedback from this consultation set out some complex issues and Health Education England (HEE) undertook further detailed work, which now needs to be considered as part of the HEE Enhancing Junior Doctors’ Working Lives programme and the workforce implementation plan.” Source location 2019-0072-Responses
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 Consult on return-of-service arrangements for doctors as part of expanding undergraduate medical education.
Verbatim wording from the response “With regard to tie-in, as part of expanding undergraduate medical education, the Government ran a consultation in 2017 and asked specific questions about the concept of return of service for doctors. The feedback from this consultation set out some complex issues and Health Education England (HEE) undertook further detailed work, which now needs to be considered as part of the HEE Enhancing Junior Doctors’ Working Lives programme and the workforce implementation plan.” Source location 2019-0072-Responses
Open published response
26 Feb 2019 Danyon Robert Chesters · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Delays in accessing NHS mental health services View source Lack of joined-up mental health care and information sharing between professionals View source Failure of private therapists to obtain information about mental health medication prescribing and its impact on therapy 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
Danyon Robert Chesters · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 2 July 2018, Danyon Robert Chesters went onto a railway line under Trafford Bridge Road and was struck by a train. The inquest heard concerns about delays in accessing mental health services, the resulting use of private therapy, and a lack of joined-up care and information sharing. It also heard concerns that private therapists might not obtain information about prescribed mental health medication and its impact on therapy.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in accessing NHS mental health services
Wider context from the report “1. Mr Chesters had previously sought help for Mental Health issues and had found significant delays in accessing services . Subsequently he had lived and worked in Germany. Whilst there he had been treated by German Mental Health Services. Following his return to England, he required further treatment. He saw his GP who indicated that there were significant delays in accessing Mental Health Services via the NHS . He felt this reflected his previous experiences with the NHS and that he could not wait and went to a private therapist. This expense caused him additional worry and he saw his therapist less regularly than would have been seen as the optimum frequency consequently. As a result of seeing a private therapist there was no joined up care in relation to his mental health and no information sharing between professionals involved in his care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of joined-up mental health care and information sharing between professionals
Wider context from the report “1. Mr Chesters had previously sought help for Mental Health issues and had found significant delays in accessing services. Subsequently he had lived and worked in Germany. Whilst there he had been treated by German Mental Health Services. Following his return to England, he required further treatment. He saw his GP who indicated that there were significant delays in accessing Mental Health Services via the NHS. He felt this reflected his previous experiences with the NHS and that he could not wait and went to a private therapist. This expense caused him additional worry and he saw his therapist less regularly than would have been seen as the optimum frequency consequently. As a result of seeing a private therapist there was no joined up care in relation to his mental health and no information sharing between professionals involved in his care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of private therapists to obtain information about mental health medication prescribing and its impact on therapy
Wider context from the report “2. The private therapist did not make further enquiries and did not show any curiosity about how he was being prescribed medication for his mental health condition . Private therapists do not appear to have any obligation to obtain information about prescribing of medication for mental health conditions or how that may impact the provision of therapy .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest in IAPT and expand community mental health services and access to psychological interventions in community and primary care.
Verbatim wording from the response “As well as investing more in IAPT, we are supporting the NHS with an additional £2.3billion investment in real terms by 2023-24 in a comprehensive expansion of mental health services. Outlined in the NHS Long Term Plan³ published in January 2019, this includes an expansion of community services and better access to psychological interventions in the community and primary care.” Source location 2019-0079-Response-by-Department-of-Health-and-Social-Care
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand IAPT services to increase access to psychological therapies for people with common mental health problems.
Verbatim wording from the response “The Five Year Forward View for Mental Health² set out a commitment to expand IAPT services and improve quality further, with an ambition to increase access to psychological therapies for an additional 600,000 people with common mental health problems each year.” Source location 2019-0079-Response-by-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 Local NHS bodies are responsible for commissioning psychological therapy services to meet their populations’ needs.
Verbatim wording from the response “It is the responsibility of the local NHS to commission services to meet the needs of their local populations. With regard to access to psychological therapies, one of the stated targets of the Improving Access to Psychological Therapies (IAPT) programme is that for new referrals, 75 per cent of people referred will enter treatment within six weeks, and 95 per cent within 18 weeks.” Source location 2019-0079-Response-by-Department-of-Health-and-Social-Care
Open published response
12 Feb 2019 Heather Louise Carey · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Insufficient psychotherapy capacity causing prolonged waits View source Lack of available in-patient psychotherapy View source Inappropriate waiting-time target for urgent psychotherapy 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
Heather Louise Carey · 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
Heather Louise Carey was admitted to mental health services in July 2017, later took an overdose of paracetamol, and was placed on a 24-week waiting list for Cognitive Analytical Therapy. She hanged herself at home on 20 December 2017. The principal concern was that lengthy waits for psychotherapy and inadequate action to address her high suicide risk may have contributed to her death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient psychotherapy capacity causing prolonged waits
Wider context from the report “The inquest identified a number of issues which likely contributed to Heather's decision to end her life. One of those issues related to the long wait following discharge before psychotherapy would begin.
At the time of Heather's admission to TGH there was no psychotherapy available to her as an in-patient because there were insufficient funds available to provide the same. I was told that had been addressed by further funding being made available.
At the time of Heather's assessment on 22.11 staffing levels were reduced, through illness and a vacancy, and there was only one psychotherapist available . That was the reason given for the 24 weeks wait .
At the inquest I heard evidence that the target waiting list was 18 weeks. Further, that by the time of the inquest that target time was being met. A target waiting time of 18 weeks, I was told, was comparable to ‘cancer waiting times’. However, it transpires that those are the maximum waiting times for non-urgent consultant led treatment for any treatment from the point of referral. Heather was already in receipt of consultant led care. Her need was urgent. Thus such a comparator on waiting times to justify an 18 weeks wait for psychotherapy is not an appropriate measure.
By letter dated 3rd January 2019 Pennine Care responded to my concerns about the long waiting list as follows,
“The CCG are currently in dialogue with Pennine Care in relation to waiting times for Secondary Care psychological therapies to ensure that existing (emphasis added) resources are effectively utilised and capacity and demand is reviewed to inform commissioning requirements.”
It was clear from the evidence heard, not only from Heather's mother and partner but from those involved in her care, that Heather had placed great faith in psychotherapy as the means by which she would bring mental stability back to her life, a release from the increasingly extreme mood swings of her bi-polar disorder. It is not difficult to imagine the despair and distress felt by Heather to be told that it would be almost 6 months before she could even begin the help/treatment she was seeking on voluntary admission some 4 months previously.
A target waiting list of 18 weeks is far too long but I was told that this was a funding issue.
Unless adequate and sufficient measures are taken to significantly reduce waiting times for acute mental ill-health, comparable to physical life threatening illnesses, NOT simply a redistribution of existing resources, more patients with mental health issues will end their lives while on a waiting list for 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 Lack of available in-patient psychotherapy
Wider context from the report “The inquest identified a number of issues which likely contributed to Heather's decision to end her life. One of those issues related to the long wait following discharge before psychotherapy would begin.
At the time of Heather's admission to TGH there was no psychotherapy available to her as an in-patient because there were insufficient funds available to provide the same . I was told that had been addressed by further funding being made available.
At the time of Heather's assessment on 22.11 staffing levels were reduced, through illness and a vacancy, and there was only one psychotherapist available. That was the reason given for the 24 weeks wait.
At the inquest I heard evidence that the target waiting list was 18 weeks. Further, that by the time of the inquest that target time was being met. A target waiting time of 18 weeks, I was told, was comparable to ‘cancer waiting times’. However, it transpires that those are the maximum waiting times for non-urgent consultant led treatment for any treatment from the point of referral. Heather was already in receipt of consultant led care. Her need was urgent. Thus such a comparator on waiting times to justify an 18 weeks wait for psychotherapy is not an appropriate measure.
By letter dated 3rd January 2019 Pennine Care responded to my concerns about the long waiting list as follows,
“The CCG are currently in dialogue with Pennine Care in relation to waiting times for Secondary Care psychological therapies to ensure that existing (emphasis added) resources are effectively utilised and capacity and demand is reviewed to inform commissioning requirements.”
It was clear from the evidence heard, not only from Heather's mother and partner but from those involved in her care, that Heather had placed great faith in psychotherapy as the means by which she would bring mental stability back to her life, a release from the increasingly extreme mood swings of her bi-polar disorder. It is not difficult to imagine the despair and distress felt by Heather to be told that it would be almost 6 months before she could even begin the help/treatment she was seeking on voluntary admission some 4 months previously.
A target waiting list of 18 weeks is far too long but I was told that this was a funding issue.
Unless adequate and sufficient measures are taken to significantly reduce waiting times for acute mental ill-health, comparable to physical life threatening illnesses, NOT simply a redistribution of existing resources, more patients with mental health issues will end their lives while on a waiting list for 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 Inappropriate waiting-time target for urgent psychotherapy
Wider context from the report “The inquest identified a number of issues which likely contributed to Heather's decision to end her life. One of those issues related to the long wait following discharge before psychotherapy would begin.
At the time of Heather's admission to TGH there was no psychotherapy available to her as an in-patient because there were insufficient funds available to provide the same. I was told that had been addressed by further funding being made available.
At the time of Heather's assessment on 22.11 staffing levels were reduced, through illness and a vacancy, and there was only one psychotherapist available. That was the reason given for the 24 weeks wait.
At the inquest I heard evidence that the target waiting list was 18 weeks . Further, that by the time of the inquest that target time was being met. A target waiting time of 18 weeks, I was told, was comparable to ‘cancer waiting times’. However, it transpires that those are the maximum waiting times for non-urgent consultant led treatment for any treatment from the point of referral. Heather was already in receipt of consultant led care. Her need was urgent . Thus such a comparator on waiting times to justify an 18 weeks wait for psychotherapy is not an appropriate measure .
By letter dated 3rd January 2019 Pennine Care responded to my concerns about the long waiting list as follows,
“The CCG are currently in dialogue with Pennine Care in relation to waiting times for Secondary Care psychological therapies to ensure that existing (emphasis added) resources are effectively utilised and capacity and demand is reviewed to inform commissioning requirements.”
It was clear from the evidence heard, not only from Heather's mother and partner but from those involved in her care, that Heather had placed great faith in psychotherapy as the means by which she would bring mental stability back to her life, a release from the increasingly extreme mood swings of her bi-polar disorder. It is not difficult to imagine the despair and distress felt by Heather to be told that it would be almost 6 months before she could even begin the help/treatment she was seeking on voluntary admission some 4 months previously.
A target waiting list of 18 weeks is far too long but I was told that this was a funding issue.
Unless adequate and sufficient measures are taken to significantly reduce waiting times for acute mental ill-health, comparable to physical life threatening illnesses, NOT simply a redistribution of existing resources, more patients with mental health issues will end their lives while on a waiting list for treatment.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make funding available to test new community mental health care models and improve timely access to psychological therapies for people with severe mental illness.
Verbatim wording from the response “This year, funding is being made available to test new models of community mental health care. This includes testing ways to improve timely access to courses of psychological therapies for people with psychosis, bipolar disorder and personality disorder. In addition, NHS England will test four-week waiting times to appropriate care, to help build our understanding of how best to introduce ambitious but achievable improvements to access, quality of care and outcomes.” 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 Local commissioners and providers are responsible for taking firm action to address the concerns and failings identified.
Verbatim wording from the response “Your report offers significant learning to the local NHS and I expect firm action to be taken by both the local commissioner and provider of services to respond to the concerns raised and the failings identified.” Source location Response from Department of Health and Social Care
Open published response
7 Feb 2019 Stephen Anthony Kennedy · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Unavailability of acute inpatient beds View source Unavailability of timely psychological services due to internal service structures and waiting lists 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
Stephen Anthony Kennedy · 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
Stephen Anthony Kennedy had a history of emotional unstable personality disorder, depression and frequent self-harm, and his condition deteriorated during 2018. He was found hanging at his home on 08/10/18 and was declared deceased. Concerns included that psychological therapy was unavailable because of service structures and long waiting lists, and that a lack of acute inpatient beds contributed to further episodes of self-harm and suicide attempts.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of acute inpatient beds
Wider context from the report “2. In August 2018 the deceased required inpatient treatment. There were no beds available and as a result he had further episodes of self-harm and suicide attempts. The availability of acute beds is a serious concern .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of timely psychological services due to internal service structures and waiting lists
Wider context from the report “1. The deceased suffered from emotional unstable personality disorder and was in crisis for most of 2018. The recommended treatment for his condition was psychological therapy. He had not had any psychological input since 2010. The inquest heard that whilst he was under the care of the home treatment team there was no access to psychology services . He had to be under the community mental health team to be able to access psychological services . There were periods when he was under the care of the community mental health team but at this time he remained on a long waiting list for psychological services . Throughout 2018 he never received any psychological services . I am concerned that the main treatment option for the deceased was not available to him due to internal structures and long waiting lists .
” 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 a community-based Severe Mental Illness offer including psychological therapies, physical healthcare, employment support, personalised care and related support.
Verbatim wording from the response “A new community-based offer for people with Severe Mental Illness will include access to psychological therapies; improved physical health care; employment support; personalised and trauma-informed care; medicines management; and support for self-harm and coexisting substance use. This will give 370,000 adults and older adults greater choice and control over their care, and support them to live well in their communities.” Source location 2019-0039-Response-by-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 Local commissioners are responsible for determining acute mental health bed provision according to their populations’ needs.
Verbatim wording from the response “On the availability of beds in the acute mental health sector, we are aware that the number of mental health beds overall have reduced and this is in large part due to the growth of care in the community. It may also be of interest to note that mental health bed occupancy rates have remained stable at between 87.1 per cent and 90.8 per cent (from Quarter 1, 2010-11 to Quarter 3, 2018-19), and that latest data for Quarter 3, 2018-19 shows a bed occupancy of 88.5 per cent. However, it remains the responsibility of local commissioners to determine the levels of service provision based on the needs of their local populations, and I note that the NHS in Birmingham and Solihull has taken action to commission a further 32 inpatient beds.” Source location 2019-0039-Response-by-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 Local NHS organisations are responsible for providing mental health services, while NHS England commissions specialised services.
Verbatim wording from the response “You will know that the provision of mental health services is a matter for the NHS locally, except where specialised services are required and NHS England is the responsible commissioner. You have issued your report to the Birmingham and Solihull Mental Health NHS Foundation Trust and the Birmingham and Solihull Clinical Commissioning Group (CCG), and I expect the local NHS to take firm action to respond to the concerns and learn from Stephen’s death to ensure the safety of healthcare services.” Source location 2019-0039-Response-by-Department-of-Health-and-Social-Care
Open published response
29 Jan 2019 Sophie Holman · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 24 Failure to supervise staff delegated to provide asthma care View source Failure to provide coordinated long-term asthma management beyond immediate attack stabilisation View source Failure to objectively assess severity and progress during acute asthma attacks View source Lack of an agreed primary-care asthma management protocol View source Failure to inform the family of the child’s risk of poor asthma outcomes View source Failure to recognise and act on chronic asthma with recurrent severe attacks View source Failure to assign overall responsibility for asthma care View source Inadequate asthma safety-netting advice and reliance on unlicensed high-dose salbutamol weaning plans View source Failure to consider referral to a specialist respiratory or severe asthma service View source Failure to analyse recurrent asthma events and the underlying chronic condition View source Failure to maintain up-to-date coded records of asthma history and hospital correspondence View source Lack of a long-term asthma management plan View source Failure to provide an appropriately trained pre-discharge asthma review View source Failure to provide post-attack asthma follow-up View source Lack of a coordinated record of asthma-related attendances View source Failure to provide a written personal asthma self-management plan View source Failure to initiate referral to a specialist respiratory service View source Failure to alert health visitors or safeguarding services to missed routine appointments View source Failure to provide a written personalised asthma action plan View source Failure to communicate changed asthma medication to primary care View source Provision of potentially dangerous advice to manage an asthma attack at home View source Failure to adjust asthma medication despite recurrent attacks View source Failure to recognise asthma risk factors for future attacks and death View source Failure to provide detailed asthma patient education and coordinated long-term management View source See 21 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Sophie Holman · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sophie Holman, a 10-year-old girl with chronic asthma, died on 13 December 2017 after collapsing during a severe asthma attack while being taken to hospital. The report identifies concerns about inadequate long-term management, fragmented records, failure to recognise the cumulative severity and risks of her asthma, lack of a coordinated asthma action plan and safety-netting, and missed opportunities for specialist referral.
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 supervise staff delegated to provide asthma care
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 long-term asthma management beyond immediate attack stabilisation
Wider context from the report “1) The medical management of this child’s asthma attacks on the innumerable occasions she presented to her general practice and hospital was concerned solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 objectively assess severity and progress during acute asthma attacks
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed primary-care asthma management protocol
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the family of the child’s risk of poor asthma outcomes
Wider context from the report “2) There was:
a. No coordinated record of these occasions
b. No analysis of the frequency or circumstances of these events
c. No analysis of the underlying chronic asthma condition
d. No appreciation of the risk factors for future attacks and death due to asthma in this child
e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments
f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines
g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history
h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented
i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of 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 to recognise and act on chronic asthma with recurrent severe attacks
Wider context from the report “In the secondary care there was:
a) Failure to recognise and act upon the underlying chronic condition punctuated by a number of severe attacks with life threatening features one of which was a near-fatal attack where Sophie was ‘blue and unresponsive’ with an oxygen saturation of 86% (2.7.2012)
b) Failure to recognise the need for and initiate referral of this child to a specialist respiratory service as recommended in the NRAD recommendations
c) Failure to take appropriate action when it was known that the family had a home nebuliser
d) Failure to implement the recommendations in the NICE Quality Statement 25, and BTS/SIGN guideline to ensure a pre-discharge review of the child’s asthma by an appropriately trained individual
e) Failure to effectively communicate changed medication in 2013 of the child to the general practitioner
f) Implementation of a hospital policy whereby this child was discharged from secondary care three times because of failure of the parents to bring the child to planned outpatient appointments
g) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-evidence based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to assign overall responsibility for asthma care
Wider context from the report “3) As in the case of two recent child asthma deaths resulting in Regulation 28 statements (Michael Uriely and Tamara Mills), despite the presence of numerous health professionals involved no single individual or organisation took overall responsibility for assuming management of her care overall .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate asthma safety-netting advice and reliance on unlicensed high-dose salbutamol weaning plans
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to consider referral to a specialist respiratory or severe asthma service
Wider context from the report “2) There was:
a. No coordinated record of these occasions
b. No analysis of the frequency or circumstances of these events
c. No analysis of the underlying chronic asthma condition
d. No appreciation of the risk factors for future attacks and death due to asthma in this child
e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments
f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines
g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history
h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented
i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of 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 to analyse recurrent asthma events and the underlying chronic condition
Wider context from the report “2) There was:
a. No coordinated record of these occasions
b. No analysis of the frequency or circumstances of these events
c. No analysis of the underlying chronic asthma condition
d. No appreciation of the risk factors for future attacks and death due to asthma in this child
e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments
f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines
g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history
h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented
i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of 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 to maintain up-to-date coded records of asthma history and hospital correspondence
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems ; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded . As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 long-term asthma management plan
Wider context from the report “2) There was:
a. No coordinated record of these occasions
b. No analysis of the frequency or circumstances of these events
c. No analysis of the underlying chronic asthma condition
d. No appreciation of the risk factors for future attacks and death due to asthma in this child
e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments
f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines
g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history
h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented
i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of 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 to provide an appropriately trained pre-discharge asthma review
Wider context from the report “In the secondary care there was:
a) Failure to recognise and act upon the underlying chronic condition punctuated by a number of severe attacks with life threatening features one of which was a near-fatal attack where Sophie was ‘blue and unresponsive’ with an oxygen saturation of 86% (2.7.2012)
b) Failure to recognise the need for and initiate referral of this child to a specialist respiratory service as recommended in the NRAD recommendations
c) Failure to take appropriate action when it was known that the family had a home nebuliser
d) Failure to implement the recommendations in the NICE Quality Statement 25, and BTS/SIGN guideline to ensure a pre-discharge review of the child’s asthma by an appropriately trained individual
e) Failure to effectively communicate changed medication in 2013 of the child to the general practitioner
f) Implementation of a hospital policy whereby this child was discharged from secondary care three times because of failure of the parents to bring the child to planned outpatient appointments
g) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-evidence based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 post-attack asthma follow-up
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 coordinated record of asthma-related attendances
Wider context from the report “2) There was:
a. No coordinated record of these occasions
b. No analysis of the frequency or circumstances of these events
c. No analysis of the underlying chronic asthma condition
d. No appreciation of the risk factors for future attacks and death due to asthma in this child
e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments
f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines
g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history
h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented
i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of 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 to provide a written personal asthma self-management plan
Wider context from the report “2) There was:
a. No coordinated record of these occasions
b. No analysis of the frequency or circumstances of these events
c. No analysis of the underlying chronic asthma condition
d. No appreciation of the risk factors for future attacks and death due to asthma in this child
e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments
f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines
g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history
h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented
i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of 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 to initiate referral to a specialist respiratory service
Wider context from the report “In the secondary care there was:
a) Failure to recognise and act upon the underlying chronic condition punctuated by a number of severe attacks with life threatening features one of which was a near-fatal attack where Sophie was ‘blue and unresponsive’ with an oxygen saturation of 86% (2.7.2012)
b) Failure to recognise the need for and initiate referral of this child to a specialist respiratory service as recommended in the NRAD recommendations
c) Failure to take appropriate action when it was known that the family had a home nebuliser
d) Failure to implement the recommendations in the NICE Quality Statement 25, and BTS/SIGN guideline to ensure a pre-discharge review of the child’s asthma by an appropriately trained individual
e) Failure to effectively communicate changed medication in 2013 of the child to the general practitioner
f) Implementation of a hospital policy whereby this child was discharged from secondary care three times because of failure of the parents to bring the child to planned outpatient appointments
g) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-evidence based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 alert health visitors or safeguarding services to missed routine appointments
Wider context from the report “5) The child’s parents failed on occasion to bring the child to routine appointments; however there was no communication by any health professional alerting the health visitors or safeguarding team regarding this . On the other hand, the child’s asthma attacks were treated in hospital and general practice ‘as an acute illness’, without detailed patient education or a co-ordinated long-term management plan. There were thus little evidence of any patient education – particularly aimed at ensuring that the child’s parents were aware of the fact that she was at risk of poor outcome even asthma death according to her risk factors; perhaps explained the behaviour of her parents.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a written personalised asthma action plan
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 changed asthma medication to primary care
Wider context from the report “In the secondary care there was:
a) Failure to recognise and act upon the underlying chronic condition punctuated by a number of severe attacks with life threatening features one of which was a near-fatal attack where Sophie was ‘blue and unresponsive’ with an oxygen saturation of 86% (2.7.2012)
b) Failure to recognise the need for and initiate referral of this child to a specialist respiratory service as recommended in the NRAD recommendations
c) Failure to take appropriate action when it was known that the family had a home nebuliser
d) Failure to implement the recommendations in the NICE Quality Statement 25, and BTS/SIGN guideline to ensure a pre-discharge review of the child’s asthma by an appropriately trained individual
e) Failure to effectively communicate changed medication in 2013 of the child to the general practitioner
f) Implementation of a hospital policy whereby this child was discharged from secondary care three times because of failure of the parents to bring the child to planned outpatient appointments
g) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-evidence based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Provision of potentially dangerous advice to manage an asthma attack at home
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions : in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 adjust asthma medication despite recurrent attacks
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise asthma risk factors for future attacks and death
Wider context from the report “2) There was:
a. No coordinated record of these occasions
b. No analysis of the frequency or circumstances of these events
c. No analysis of the underlying chronic asthma condition
d. No appreciation of the risk factors for future attacks and death due to asthma in this child
e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments
f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines
g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history
h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented
i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of 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 to provide detailed asthma patient education and coordinated long-term management
Wider context from the report “5) The child’s parents failed on occasion to bring the child to routine appointments; however there was no communication by any health professional alerting the health visitors or safeguarding team regarding this. On the other hand, the child’s asthma attacks were treated in hospital and general practice ‘as an acute illness’, without detailed patient education or a co-ordinated long-term management plan . There were thus little evidence of any patient education – particularly aimed at ensuring that the child’s parents were aware of the fact that she was at risk of poor outcome even asthma death according to her risk factors; perhaps explained the behaviour of her parents.
” Open source report
11 Jan 2019 Jacqueline Marie Elliott · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to document and justify the volume of tramadol prescribed despite recorded non-compliance and self-medication View source Failure of the GP practice recording system to accurately distinguish repeat and acute prescriptions View source Failure to explore alternatives to repeated painkiller prescribing for persistent back pain View source Lack of continuity of care preventing a clinician from maintaining an overview of the patient and her health View source Lack of detail in GP and ANP consultation notes View source Failure to document the extent and issues considered during medication reviews View source Medication reviews failing to provide a full overview of prescribed long-term medication View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Jacqueline Marie Elliott · 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
Jacqueline Marie Elliott, who had a long-standing history of back pain, was found deceased at home on 9 August 2018. Post-mortem and toxicology findings identified reduced liver function and significant toxicity from a combination of drugs. Concerns included inaccurate prescription records, insufficient clinical notes and medication-review detail, prescribing of 100 tramadol tablets despite a recorded history of non-compliance and self-medication, and a lack of continuity of care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to document and justify the volume of tramadol prescribed despite recorded non-compliance and self-medication
Wider context from the report “4. There was a recorded history of non-compliance and deliberate self-medication of painkillers by Mrs Elliott. Despite that a GP immediately before her death in a telephone consultation prescribed her with 100 tramadol tablets whilst recording that she needed an urgent review. The rationale for prescribing this volume of medication was unclear from the notes ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of the GP practice recording system to accurately distinguish repeat and acute prescriptions
Wider context from the report “1. The GP practice computer recording system showed drugs that were clearly on repeat prescription as drugs that were acute prescriptions. As a result the inquest was told that the medication reviews carried out would not pick up on and would not review those prescriptions. The medication reviewer would not therefore have a full overview of her prescribed long term medication;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 explore alternatives to repeated painkiller prescribing for persistent back pain
Wider context from the report “5. There was a lack of continuity of care. Mrs Elliott saw a variety of different locum GPs. This meant that no clinician had an overview of her and her health. As a result, painkillers were repeatedly prescribed and other potential ways of managing her persistent back pain were not explored . This led to a significant reliance by Mrs Elliott on painkillers to manage her on going back problems. The inquest was told that the lack of continuity of care was due to a national shortage of GPs and was a national not local issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of continuity of care preventing a clinician from maintaining an overview of the patient and her health
Wider context from the report “5. There was a lack of continuity of care. Mrs Elliott saw a variety of different locum GPs. This meant that no clinician had an overview of her and her health. As a result, painkillers were repeatedly prescribed and other potential ways of managing her persistent back pain were not explored. This led to a significant reliance by Mrs Elliott on painkillers to manage her on going back problems. The inquest was told that the lack of continuity of care was due to a national shortage of GPs and was a national not local issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of detail in GP and ANP consultation notes
Wider context from the report “2. The notes made by GPs and the ANP who had seen her/had telephone consultations lacked detail and so it was difficult to assess what information had been provided previously and what advice she had been given ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to document the extent and issues considered during medication reviews
Wider context from the report “3. There was no detail provided in the notes at the inquest of the extent or issues considered during the medication reviews that were recorded as having taken place ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Medication reviews failing to provide a full overview of prescribed long-term medication
Wider context from the report “1. The GP practice computer recording system showed drugs that were clearly on repeat prescription as drugs that were acute prescriptions. As a result the inquest was told that the medication reviews carried out would not pick up on and would not review those prescriptions . The medication reviewer would not therefore have a full overview of her prescribed long term medication ;
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations