18 Jul 2018 Mohamed Rahman · Prevention of Future Deaths report Manchester (West)
View report summary
Concerns raised 6 Failure to contemporaneously document needle insertion and withdrawal times and ultrasound fetal heartbeat monitoring time View source Lack of clinical guidance documents and procedures for unequivocal confirmation of fetal demise View source Lack of a sensitive, lay-language leaflet fully explaining the feticide process to parents View source Diminishing of scans for confirmation of fetal death View source Failure to formally record the exact time of cessation of fetal heart activity View source Failure to perform the interval fetal heart check at least 20 minutes later and for a full 2 minutes View source See 3 more concerns
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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
Mohamed Rahman · 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
Baby Mohamed Rahman was born at 01:45 on 17 February 2018 after an elective feticide procedure and was confirmed dead at 02:48 that day. The principal concerns were that fetal asystole was not unequivocally confirmed before discharge, that the mother and professionals were unprepared for the birth, and that documentation and guidance about confirming fetal demise and explaining the procedure to parents required consideration.
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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 contemporaneously document needle insertion and withdrawal times and ultrasound fetal heartbeat monitoring time
Wider context from the report “2. The Consultant Obstetrician giving evidence confirmed the need to formally record the exact time at which fetal heart activity ceased at the interval scan which should be at least 20 minutes later with the interval fetal heart check for a full 2 minutes to avoid more transient than permanent asystole. Following the case involving baby Mohammed written Fetal Medicine Guidelines were amended (copy attached). The Consultant Obstetrician agreed that it would be good practice to contemporaneously document the time of insertion and withdrawal of needle and the time at which the fetal heartbeat was monitored on ultrasound .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 clinical guidance documents and procedures for unequivocal confirmation of fetal demise
Wider context from the report “3. Without intending to be prescriptive, it is the opinion that other Departments nationally aware of the tragic sequence of events which took place in Greater Manchester and should consider the implementation of clinical guidance documents and procedures to facilitate unequivocal confirmation of fetal demise .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 sensitive, lay-language leaflet fully explaining the feticide process to parents
Wider context from the report “4. Consideration should also be given to the desirability of a leaflet for parents which fully explains the feticide process using appropriately sensitive and lay terminology .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Diminishing of scans for confirmation of fetal death
Wider context from the report “1. Mother in particular but also the experienced professionals involved were wholly unprepared for what they witnessed and the feelings of birth when “stunned”, “shocked” and “distressed” were amongst the epithets given in evidence to describe their experience with the birth. The Neonatal team were not present and would not have expected to be present and had to be called urgently to review what had occurred. However well-intentioned - the attempt to reduce the time that a patient waits for the Department of Fetal Medicine scan is time performed by diminishing the scan for confirmation of fetal death contributed to this unintended outcome after termination of the pregnancy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to formally record the exact time of cessation of fetal heart activity
Wider context from the report “2. The Consultant Obstetrician giving evidence confirmed the need to formally record the exact time at which fetal heart activity ceased at the interval scan which should be at least 20 minutes later with the interval fetal heart check for a full 2 minutes to avoid more transient than permanent asystole. Following the case involving baby Mohammed written Fetal Medicine Guidelines were amended (copy attached). The Consultant Obstetrician agreed that it would be good practice to contemporaneously document the time of insertion and withdrawal of needle and the time at which the fetal heartbeat was monitored on ultrasound.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to perform the interval fetal heart check at least 20 minutes later and for a full 2 minutes
Wider context from the report “2. The Consultant Obstetrician giving evidence confirmed the need to formally record the exact time at which fetal heart activity ceased at the interval scan which should be at least 20 minutes later with the interval fetal heart check for a full 2 minutes to avoid more transient than permanent asystole. Following the case involving baby Mohammed written Fetal Medicine Guidelines were amended (copy attached). The Consultant Obstetrician agreed that it would be good practice to contemporaneously document the time of insertion and withdrawal of needle and the time at which the fetal heartbeat was monitored on ultrasound.
” Open source report
29 Jun 2018 Lindsey Tyrrell · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Failure to routinely test for toxoplasmosis in allogeneic stem cell transplant patients presenting with signs of infection 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
Lindsey Tyrrell · 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
Lindsey Tyrrell, who had undergone an allogeneic stem cell transplant and was immunosuppressed, developed an infection and deteriorated before dying on 3 July 2017. Toxoplasmosis was identified retrospectively in blood and cerebrospinal fluid; the principal concern was that testing for toxoplasmosis was not routinely carried out at the Christie Hospital in comparable transplant patients presenting with signs of infection, and that learning from the incident should be shared nationally.
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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 Failure to routinely test for toxoplasmosis in allogeneic stem cell transplant patients presenting with signs of infection
Wider context from the report “I heard evidence at the Inquest that toxoplasmosis is carried by about 30% of the population, however, prior to Mrs Tyrell's death testing for this infection was not routinely carried out at the Christie Hospital on patients who had received an allogeneic stem cell transplant and who had subsequently presented with signs of infection I heard evidence that, following Mrs Tyrell's death, testing for toxoplasmosis is now undertaken at the Christie Hospital when stem cell transplant patients present in similar circumstances However, there was no evidence before me as to the practice of other specialist blood cancer care units or hospitals in similar circumstances It seems appropriate that the learning from this incident at a local level should be shared on a nationwide basis
” Open source report
Concerns raised 2 Lack of a legal requirement for care-home carers to carry a mobile or portable telephone for summoning assistance View source Lack of a requirement for care providers to ensure that care-home carers have first-aid training 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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ASHLEY ERNEST NOTSON · 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
Ashley Notson died at age 55 after choking on a piece of meat at the care home where he lived, later dying in hospital from hypoxic brain injury resulting from the choking episode. The inquest raised concerns that the law did not require care-home carers to have first-aid training or to have access to a mobile or portable telephone to summon assistance without leaving the person they were caring for.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a legal requirement for care-home carers to carry a mobile or portable telephone for summoning assistance
Wider context from the report “The inquest heard that the law currently does not require care providers to ensure that carers in a care home have had first aid training. Fortunately, the carer on duty at the time of incident was trained in first aid and did what he could to assist Ashley, but a similar situation could clearly arise in another care home without such a suitably trained carer present.
The inquest also heard that, at this care home, all carers carry a mobile or portable telephone so that they can summon assistance if an incident occurs without having to leave the person they are looking after , but that this was not a legal requirement either .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 requirement for care providers to ensure that care-home carers have first-aid training
Wider context from the report “The inquest heard that the law currently does not require care providers to ensure that carers in a care home have had first aid training . Fortunately, the carer on duty at the time of incident was trained in first aid and did what he could to assist Ashley, but a similar situation could clearly arise in another care home without such a suitably trained carer present .
The inquest also heard that, at this care home, all carers carry a mobile or portable telephone so that they can summon assistance if an incident occurs without having to leave the person they are looking after, but that this was not a legal requirement either.
” Open source report
Concerns raised 2 Absence of a national safety-netting system for biliary stents View source Failure of clinical guidance to define ‘short term’ for biliary stent use View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Stephen Whitehead · 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 Whitehead was admitted with abdominal symptoms on 6 February 2018 and deteriorated despite intensive treatment, dying in hospital on 8 February 2018. The report identified concerns about the absence of a national registry or safety-netting system for biliary stents and the lack of a clear definition of “short-term” use in clinical guidance.
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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 Absence of a national safety-netting system for biliary stents
Wider context from the report “1. The absence of a national ‘safety-netting’ system (stent registry) , akin to that already established for ureteric stents (a web-based registry). There is no equivalent for biliary stents . Without a safety netting system, I am concerned that there is a real risk that patients will remain susceptible to what is medically recognised as the ‘phenomenon of the forgotten biliary stent’, resulting in future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical guidance to define ‘short term’ for biliary stent use
Wider context from the report “2. Definition of ‘short-term’ in clinical guidance - during the course of the evidence I heard that National Guidelines on the management of common bile duct stones currently indicates that the short term use of endoscopic biliary stents followed by further ERCP (or surgery) is an established and safe management option. However, the guidelines do not provide an operational definition of ‘short term’ . It is therefore unclear as to what is ‘safe’ in terms of timeframe .
” 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 existing definition of “short term” is understood by clinicians, and the relevant NICE recommendations remain appropriate without further clarification.
Verbatim wording from the response “On your second matter of concern relating to the definition of ‘short term’ in clinical guidance, my officials have sought the views of NICE.” Source location 2018-0293-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 A national stent registry would not necessarily have prevented the outcome because the apparent shortcomings concerned local care arrangements.
Verbatim wording from the response “This view is supported by the National Institute for Health and Clinical Excellence (NICE) which points out that in this case there appeared to be an intention to remove the stent but this did not happen due to an administrative” Source location 2018-0293-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 A national stent registry is not required because existing guidance, communication, management-plan recording and proposed safety-net arrangements are considered sufficient.
Verbatim wording from the response “Your report was issued to the British Society of Gastroenterology (BSG) and I understand the Society has provided a response. You will therefore be aware that after careful consideration, the Society is of the opinion that a national stent registry is not required, instead pointing to the existing guidance available and the need for clear communication between medical professionals and with the patient, as well as the clear recording of next steps in management plans.” Source location 2018-0293-Response-by-Department-of-Health-and-Social-Care
Open published response
26 Jun 2018 Angela Marion Turner · Prevention of Future Deaths report Manchester West
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Concerns raised 1 Inadequate response to calls made to NHS 111 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
Angela Marion Turner · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Angela Marion Turner developed intense pain after a sudden-onset headache, and her son’s call to NHS 111 went unanswered for approximately 45 minutes. She was later assessed at a Walk-In Centre and discharged home, was found collapsed the following day, and died on 10 January 2018 from a subarachnoid haemorrhage; the substantive concern was the inadequate response to the NHS 111 call.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate response to calls made to NHS 111
Wider context from the report “Wholly inadequate response to the call made to NHS 111 on the afternoon of 30th December 2017.
” Open source report
25 Jun 2018 Marjorie McMahon · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Delays in ambulance and paramedic attendance for level 2 priority calls 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
Marjorie McMahon · 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
Marjorie McMahon became increasingly unwell at Cherry Tree House and was taken to hospital on 7 March 2018, where she received treatment before dying on 8 March 2018. The principal concern was the delay in ambulance and paramedic attendance despite her being categorised as a level 2 priority, with an 8-minute guideline response time.
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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 ambulance and paramedic attendance for level 2 priority calls
Wider context from the report “Mrs McMahon was correctly categorised as a level 2 priority at 1.30 pm on the 7th March 2018 when the North West Ambulance Service were first contacted in respect of her deteriorating condition. Despite this, due to high demand on the service and available resources, she was not attended to for nearly 1 ½ hours (in respect of the paramedic) and 2 hours (in respect of attendance of the ambulance). The guideline response time was confirmed to be 8 minutes.
” Open source report
29 May 2018 Brian Leonard Bicat · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 6 Unavailability of verbal fire-risk warnings from healthcare professionals for retail and online purchases View source Lack of accurate national data on fire incidents involving paraffin-based skin products View source Inconsistent fire-risk alerts and warnings across NHS prescribing systems View source Lack of healthcare professional awareness of the fire hazard from low-paraffin emollient creams View source Failure to display fire-risk warnings on all product packaging View source Fire hazard from paraffin-based ointments and low-paraffin emollient creams View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Brian Leonard Bicat · 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
Brian Leonard Bicat sustained severe burns at home on 22 September 2017 when his dressing gown caught fire while he was smoking a cigarette. He died later that day from his extensive cutaneous burns, with evidence indicating that paraffin-based emollient creams and ointments increased the speed and intensity of the fire. The principal concerns were that low-paraffin emollients may pose a fire hazard, that warnings were not displayed consistently on packaging or communicated by healthcare professionals, and that related prescribing alerts and incident data were inconsistent or incomplete.
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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 Unavailability of verbal fire-risk warnings from healthcare professionals for retail and online purchases
Wider context from the report “Members of the public are able to purchase such products in retail outlets and online where verbal warnings from healthcare professionals are not 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 Lack of accurate national data on fire incidents involving paraffin-based skin products
Wider context from the report “Consider a review of the current effectiveness of obtaining fire incident reports involving paraffin based skin products since there is currently a lack of accurate national data involving paraffin based skin products
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 fire-risk alerts and warnings across NHS prescribing systems
Wider context from the report “The NHS prescribing systems (system One and Optimise) appear to be updated by individual CCG’s resulting inconsistent alerts and warnings .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of healthcare professional awareness of the fire hazard from low-paraffin emollient creams
Wider context from the report “Health care professionals in both hospital and community setting may not be aware of the potential fire hazard poised by emollient creams which contain a low level of paraffin
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 display fire-risk warnings on all product packaging
Wider context from the report “Warnings of such risks are not displayed on all product packaging
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Fire hazard from paraffin-based ointments and low-paraffin emollient creams
Wider context from the report “Paraffin based ointments and emollient creams which contain a low level of paraffin pose a potential fire hazard risk
” Open source report
25 May 2018 Robin Damien Richards · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 8 Failure to inspect CQC-registered placement suitability View source Failure of communication with family and between Trust staff View source Shortage of suitable supported accommodation for people diagnosed with Asperger's Syndrome View source Failure to communicate directly with the person in crisis View source Inadequate risk assessment and subsequent risk management View source Failure of communication between Trust staff and placement staff View source Lack of clarity in discharge plans and placement expectations View source Inadequate handover of mental health care information View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Robin Damien Richards · 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
Robin Damien Richards, who had a history of mental health problems and diagnoses including Asperger's Syndrome, ADHD and a learning disability, was found suspended by his belt at supported accommodation on 29 June 2015 and died in hospital on 3 July 2015. Concerns included a shortage of suitable supported accommodation, the suitability and inspection of his placement, and shortcomings in communication, handover, discharge planning, care planning and risk assessment.
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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 inspect CQC-registered placement suitability
Wider context from the report “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests.
(2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected.
(3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified;
a) Poor communication with family and between Trust staff.
b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement.
c) An inadequate handover.
d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him.
e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 communication with family and between Trust staff
Wider context from the report “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests.
(2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected.
(3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified;
a) Poor communication with family and between Trust staff.
b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement.
c) An inadequate handover.
d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him.
e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Shortage of suitable supported accommodation for people diagnosed with Asperger's Syndrome
Wider context from the report “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests.
(2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected.
(3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified;
a) Poor communication with family and between Trust staff.
b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement.
c) An inadequate handover.
d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him.
e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 directly with the person in crisis
Wider context from the report “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests.
(2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected.
(3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified;
a) Poor communication with family and between Trust staff.
b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement.
c) An inadequate handover.
d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him.
e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 risk assessment and subsequent risk management
Wider context from the report “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests.
(2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected.
(3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified;
a) Poor communication with family and between Trust staff.
b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement.
c) An inadequate handover.
d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him.
e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 communication between Trust staff and placement staff
Wider context from the report “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests.
(2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected.
(3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified;
a) Poor communication with family and between Trust staff.
b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement.
c) An inadequate handover.
d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him.
e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in discharge plans and placement expectations
Wider context from the report “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests.
(2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected.
(3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified;
a) Poor communication with family and between Trust staff.
b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement.
c) An inadequate handover.
d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him.
e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 handover of mental health care information
Wider context from the report “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests.
(2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected.
(3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified;
a) Poor communication with family and between Trust staff.
b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement.
c) An inadequate handover.
d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him.
e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards
” Open source report
24 May 2018 Rosalind Flett · Prevention of Future Deaths report South London
View report summary
Concerns raised 1 Ambiguity in search policies concerning clothing removal short of an intimate search 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
Rosalind Flett · 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
Rosalind Flett, who was detained under section 2 of the Mental Health Act and subject to enhanced observation and regular searches, used a razor blade to make a deep laceration to her neck in full view of nursing staff and died shortly thereafter. The report identified an ambiguity in search policies about whether staff could ask her to remove her bra, despite her history of concealing razor blades and previous incidents of cutting.
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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 Ambiguity in search policies concerning clothing removal short of an intimate search
Wider context from the report “The Trust’s policy on searching was made in accordance with the Mental Health Act 1983 Code of Practice. However, there appeared to be a gap between “an advanced search” which was limited to a pat down of clothing and did not allow for clothing to be removed to underwear, and an “intimate search” which deals with items concealed in a body orifice . Staff were therefore given the impression that they could not ask Ms Flett to remove her bra for searching .
Since the conclusion of the inquest I have been informed that the local Trust search policy is to be amended. However, the ambiguity appears to exist in other Trust policies , and I therefore make this report in order to bring the matter to wider attention.
” Open source report
21 May 2018 Carter Isaac Jepson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of a process or protocol for prescribing medication to stop lactation after unexpected child loss 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
Carter Isaac Jepson · 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
Carter Isaac Jepson was found not breathing in his Moses basket on 4 November 2017 and died in hospital later that morning. His death was attributed to natural causes, although the precise cause could not be ascertained. The inquest heard that his mother's psychological distress was exacerbated by the absence of a process or protocol for prescribing medication to stop lactation after his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a process or protocol for prescribing medication to stop lactation after unexpected child loss
Wider context from the report “The inquest heard that Carter had been breastfed. Following his death, his mother was significantly impacted, psychologically, by his loss. The inquest heard that this was exacerbated because there was no process/protocol in place to prescribe her medication to stop lactation . As a result she continued to lactate whilst dealing with her loss. The inquest heard that the SUDC paediatricians dealing with the case had identified this as a national issue relating to breastfeeding mothers dealing with the trauma of the unexpected loss of their child.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS trusts are responsible for comprehensive bereavement guidance covering lactation-suppression information and support.
Verbatim wording from the response “It is therefore for NHS trusts to ensure they have in place comprehensive, compassionate guidance for bereavement care which includes the provision of information and support on lactation suppression, based on best practice and evidence.” Source location 2018-0154-Response-by-Department-of-Health
Open published response
21 May 2018 Alfie Scambler-Holt · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Failure to standardise PEWS scoring systems and escalation processes across trusts 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
Alfie Scambler-Holt · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alfie Scambler-Holt, who had cerebral palsy and complex health needs, became seriously unwell at home and was admitted to Stepping Hill Hospital with suspected sepsis. He died after suddenly stopping breathing during treatment. The report identified concerns about differing PEWS scoring systems and escalation processes between trusts because there was no national system.
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 standardise PEWS scoring systems and escalation processes across trusts
Wider context from the report “The inquest heard that since the death of Alfie Scambler -Holt the Trust had done a significant amount of work looking at PEWS scores and escalation processes. The Clinical Lead for Paediatrics told the inquest that one of the challenges was that there was no national PEWS scoring system . As a result there were different PEWS scoring systems in operation in different trusts . This meant that staff dealing with children and moving/rotating between Trusts would not necessarily be dealing with the same system and escalation processes .
” Open source report
28 Apr 2018 Sara Antonia MORAN, known as Sally · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 1 Failure to ensure mental health professionals have manageable caseloads 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
Sara Antonia MORAN, known as Sally · 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
Sara Antonia MORAN, known as Sally, was found deceased at home on 22 April 2017 after being reported missing; the medical cause of death was morphine toxicity and the inquest conclusion was drug related. The report raised concern that excessive demands on mental health professionals and inadequate staffing could result in service users not receiving the attention they need, potentially with fatal consequences.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure mental health professionals have manageable caseloads
Wider context from the report “I am concerned that if mental health professionals are expected to provide care to an excessive number of service users – many of whom inevitably pose significant challenges – then there a genuine risk of future deaths arises as a result of this. Sara Moran had a history of drug and mental health problems. Although I did not find that the care afforded to Sara contributed to her fatal outcome this does not prevent me from writing this report. If mental health professionals are finding themselves struggling to provide the level of service that Service Users such as Sara require then such demands in my judgement inevitably pose a significant risk that one or more such Service Users may not receive the level of attention they need and with potentially fatal consequences .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual NHS trusts are responsible for determining staffing numbers and types and ensuring sufficient trained and competent staff.
Verbatim wording from the response “I should firstly point out that individual NHS Trusts are responsible for the number and type of staff they employ and for ensuring there is a sufficiency of staff trained and competent to carry out their duties.” Source location 2018-0133-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing CQC registration requirements already require providers to deploy sufficient suitably qualified, competent, skilled and experienced staff.
Verbatim wording from the response “Appropriate staffing levels are already a core element of the Care Quality Commission’s (CQC’s) registration regime underpinned by legislation. All providers of regulated activities must be registered with the CQC and meet the registration requirements. The 16 safety and quality requirements set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 include a requirement for the deployment of sufficient numbers of suitably qualified, competent, skilled and experienced persons.” Source location 2018-0133-Response-by-Department-of-Health
Open published response
20 Apr 2018 Novia Emilia Delima · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of systems ensuring early paediatrician review of very young children in out-of-hours emergency department care View source Failure of emergency department on-call arrangements to trigger consultant attendance after long waits View source Failure to meet Manchester triage time targets 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
Novia Emilia Delima · 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
Novia Emilia Delima was brought to hospital on 25 July 2016 after blood was seen in her nappies, and she was not seen by a doctor until several hours after triage. She was subsequently diagnosed with sepsis, deteriorated despite treatment, and died later that day from neonatal herpes simplex and E. coli septicaemia. The concerns included delays in emergency assessment, the need for early paediatric input for very young babies, and consultant call-out arrangements that did not require attendance solely because of long waits.
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 systems ensuring early paediatrician review of very young children in out-of-hours emergency department care
Wider context from the report “2. The inquest heard that very young babies present significant challenges in diagnosis and early clinical input by a clinician experienced in dealing with young children was important. The trust had brought in significant changes to how it dealt with paediatric cases in ED since the death of Novia. This includes early clinical involvement of a paediatric clinician for babies between 0- 6 months due to their recognition of challenges of diagnosis in very young children. The inquest heard that not all trusts, nationally, have systems that ensure very young children are seen by a paediatrician at an early stage particularly in an OOH situation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of emergency department on-call arrangements to trigger consultant attendance after long waits
Wider context from the report “3.on the night in question the inquest heard that a consultant was on call for ED but was not called in despite the significant delays in ED. The inquest heard that the ED on call consultant arrangements meant that long wait times would not in themselves trigger on call consultants being asked to attend the hospital .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to meet Manchester triage time targets
Wider context from the report “1. The Trust had adopted the Manchester triage system but due to demand on the ED the time identified through the triage system could not be met . The Manchester triage tool is widely used but the inquest heard that often across EDs the targets set by the triage tool are not met ;
” Open source report
19 Apr 2018 Adrian Jennings · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Lack of a clear system for joined-up discharge planning between primary and secondary mental health services View source Failure of the Lorenzo electronic booking and triage system to capture key information about police conveyance View source Unavailability of identified mental health support services because they were not commissioned View source Failure to use one Trust-wide IT system for information sharing between professionals involved in care View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Adrian Jennings · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Adrian Jennings had a history of mental health issues and self-harm attempts and died on 10 December 2016 after taking a fatal cocktail of drugs and alcohol. The principal concerns included poor communication and inadequate discharge support planning between mental health services, failures to record key information when he arrived at hospital, and a policy gap concerning the reporting of high-risk absconding before triage.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear system for joined-up discharge planning between primary and secondary mental health services
Wider context from the report “2.there was no clear system for the primary and secondary mental health services of the mental health trust ,Pennine Care, to develop a joined up discharge plan following a stay on the mental health ward ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of the Lorenzo electronic booking and triage system to capture key information about police conveyance
Wider context from the report “4. Tameside Hospital cannot change their electronic booking in/triage system to allow them to include drop down boxes for key information such as the fact that Police Officers have brought an individual to the Hospital because it is a national IT system. Any trust operating the Lorenzo system will struggle to capture this information at booking 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 Unavailability of identified mental health support services because they were not commissioned
Wider context from the report “3. a need for a type of mental health support service had been identified by the mental health trust Pennine Care but it could not be delivered because the Trust had not been commissioned to deliver the service ; and
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to use one Trust-wide IT system for information sharing between professionals involved in care
Wider context from the report “1. The inquest heard evidence that the Mental Health Trust had not introduced one IT system across the Trust , which impacted on information sharing between professionals involved in his care ;
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the Mental Health Act Code of Practice to set guiding principles for improving patient care, including involving carers and families in care decisions.
Verbatim wording from the response “The Mental Health Act 1983 Code of Practice¹, whilst being statutory guidance for providers of services under the Act, should be observed as best practice by all commissioners and providers of services to people who may become subject to the Act. We revised the Code of Practice in 2015 and set out guiding principles to” Source location 2018-0111-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England leads work to address secure cross-service record sharing and should provide information about its progress.
Verbatim wording from the response “You raise two matters of concern relating to IT, firstly on the lack of a single IT system across the Pennine Care NHS Foundation Trust and its impact on patient information sharing. We recognise there are challenges across the service in enabling secure record sharing and there are a number of steps being taken to address this, led by NHS England. I will leave it to NHS England to advise on the work currently underway around the Global Digital Exemplar Programme and the Local Health and Care Record Exemplars that are designed to join up and digitise health systems, providing clinicians with timely access to patient clinical information.” Source location 2018-0111-Response-by-Department-of-Health
Open published response
16 Apr 2018 Karen Jane Edgar · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 2 Delays in obtaining mental health treatment for children and young people in Cumbria View source Underfunding of mental health services for children and young people in Cumbria 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
Karen Jane Edgar · 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
Karen Jane Edgar had emotional and behavioural difficulties and was referred to CAMHS in October 2015, aged 15. She received delayed and limited mental health support, including gaps in family therapy, individual therapy, risk reassessment and care planning, before she died after hanging herself on 8 April 2017. The report raised concerns about underfunded child and adolescent mental health services, delays in treatment and inadequate resources and 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 Delays in obtaining mental health treatment for children and young people in Cumbria
Wider context from the report “(1) The provision of mental health services for children and young people in Cumbria is underfunded.
(2) There are long delays in getting 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 Underfunding of mental health services for children and young people in Cumbria
Wider context from the report “(1) The provision of mental health services for children and young people in Cumbria is underfunded.
(2) There are long delays in getting 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 over £300 million in additional funding available after the consultation.
Verbatim wording from the response “Additional funding of over £300 million will be made available post consultation. The consultation closed on 2 March 2018 and we are currently finalising the response to the consultation, which will be published in due course.” Source location 2018-0106-Response-by-Department-of-Health-Social-Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create new mental health support teams working directly with schools and colleges.
Verbatim wording from the response “The Green Paper includes plans to improve access to services and mental health support in schools including:” Source location 2018-0106-Response-by-Department-of-Health-Social-Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make an additional £1.4 billion available to improve mental health services for children and young people, including £150 million for eating disorders.
Verbatim wording from the response “The Government is already making an additional £1.4 billion available, which includes £150 million for eating disorders, to improve mental health services for children and young people with mental health problems.” Source location 2018-0106-Response-by-Department-of-Health-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 Pilot a four-week waiting time for NHS children and young people’s mental health services.
Verbatim wording from the response “The Green Paper includes plans to improve access to services and mental health support in schools including:” Source location 2018-0106-Response-by-Department-of-Health-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 Commissioning mental health services in Cumbria is the responsibility of local NHS commissioners.
Verbatim wording from the response “I would first like to explain that the commissioning of mental health services in Cumbria is a matter for the local NHS. I note that you have issued your report to local commissioners, the North Cumbria and the Morecambe Bay Clinical Commissioning Groups (CCGs), as well as the Cumbria Partnership NHS Foundation Trust, and I hope their response will be helpful.” Source location 2018-0106-Response-by-Department-of-Health-Social-Care
Open published response
12 Apr 2018 Patricia Ann Heslop · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 15 Fragmented care information systems View source Failure to update care plans View source Lack of an effective observation-based early warning system View source Incomplete or inaccurate care records View source Failure to provide families with regular information about care View source Failure to collate changes in residents' presentation View source Failure to review care documentation View source Unclear responsibility for completing care forms View source Lack of comprehensive induction and ongoing dementia training View source Failure to report falls View source Failure to obtain timely witness statements after falls View source Failure to recognise the significance of changes in condition View source Failure to record changes in residents' presentation View source Delays in obtaining timely treatment View source Failure to recognise the need for hospital x-ray after suspected unwitnessed falls View source See 12 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
Patricia Ann Heslop · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Patricia Ann Heslop, a 75-year-old care home resident with vascular dementia, suffered an unwitnessed fall and fractured her right neck of femur. Following surgery and a period of immobility, she developed acute bronchopneumonia and died on 9 April 2017. The report raised concerns about the unreported fall, changes in mobility and presentation not being recorded or communicated, incomplete care records, delayed treatment, and staff training and information systems.
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 Fragmented care information systems
Wider context from the report “7. There were numerous forms for staff to complete and read, instead of an integrated IT system . Staff were unsure, who had to complete the forms either for themselves, or on behalf others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 update care plans
Wider context from the report “4. There was evidence that care plans had not been updated , various documents not reviewed or read by others, as well as that records were incomplete or inaccurate. For example, the impression was given of Patricia being in a chair for 13 continuous hours and in bed for 17 hours with concerns about her fluid/nutritional intake as well as her personal needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 effective observation-based early warning system
Wider context from the report “3. A number of terms were used about Patricia's developing condition: “lethargy”, “mobility fluctuating”, “gone off her feet”, “struggled to stand” and “non-weight bearing”, yet no significance was placed upon what this really meant alongside an effective early warning system associated with observations .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Incomplete or inaccurate care records
Wider context from the report “4. There was evidence that care plans had not been updated, various documents not reviewed or read by others, as well as that records were incomplete or inaccurate . For example, the impression was given of Patricia being in a chair for 13 continuous hours and in bed for 17 hours with concerns about her fluid/nutritional intake as well as her personal needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 families with regular information about care
Wider context from the report “2. There appears to have been a change in Patricia's presentation and a number of factors, which were not collated in the days preceding her hospital admission including:
• the unusual and regular use of a wheelchair;
• the rocking manoeuvre by two members of staff to get Patricia from her chair;
• the fact that two members of staff would walk with Patricia.
These matters were not recorded, as they ought to have been, nor were the family informed , as they should have been.
It is important that family members have confidence in the provision of care to a loved one and have regular information provided 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 Failure to collate changes in residents' presentation
Wider context from the report “2. There appears to have been a change in Patricia's presentation and a number of factors, which were not collated in the days preceding her hospital admission including:
• the unusual and regular use of a wheelchair;
• the rocking manoeuvre by two members of staff to get Patricia from her chair;
• the fact that two members of staff would walk with Patricia.
These matters were not recorded, as they ought to have been, nor were the family informed, as they should have been.
It is important that family members have confidence in the provision of care to a loved one and have regular information provided 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 Failure to review care documentation
Wider context from the report “4. There was evidence that care plans had not been updated, various documents not reviewed or read by others , as well as that records were incomplete or inaccurate. For example, the impression was given of Patricia being in a chair for 13 continuous hours and in bed for 17 hours with concerns about her fluid/nutritional intake as well as her personal needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for completing care forms
Wider context from the report “7. There were numerous forms for staff to complete and read, instead of an integrated IT system. Staff were unsure, who had to complete the forms either for themselves, or on behalf others .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of comprehensive induction and ongoing dementia training
Wider context from the report “8. Comprehensive induction and on-going dementia training of staff may be beneficial to better appreciate the needs of those who suffer with dementia and the communication difficulties they have.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to report falls
Wider context from the report “1. The fall was unwitnessed and went unreported .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 timely witness statements after falls
Wider context from the report “5. Despite Patricia having fallen sometime in the early part of November no attempts were made at that time to take statements from various witnesses about the fall while events were fresh in their memories . Instead that had to be done as part of the Inquest process. That said, if there was a reluctance to be frank and candid then it was unlikely to manifest itself at the Inquest. It was deeply disappointing that vital information was not to hand about a resident having fallen or being found or assisted after a fall, especially when Patricia had a known history of falls.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the significance of changes in condition
Wider context from the report “3. A number of terms were used about Patricia's developing condition: “lethargy”, “mobility fluctuating”, “gone off her feet”, “struggled to stand” and “non-weight bearing”, yet no significance was placed upon what this really meant alongside an effective early warning system associated with observations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to record changes in residents' presentation
Wider context from the report “2. There appears to have been a change in Patricia's presentation and a number of factors, which were not collated in the days preceding her hospital admission including:
• the unusual and regular use of a wheelchair;
• the rocking manoeuvre by two members of staff to get Patricia from her chair;
• the fact that two members of staff would walk with Patricia.
These matters were not recorded , as they ought to have been, nor were the family informed, as they should have been.
It is important that family members have confidence in the provision of care to a loved one and have regular information provided 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 Delays in obtaining timely treatment
Wider context from the report “6. The delay in getting treatment for Patricia in a more timely way did not cause or contribute to her death, but Patricia was probably in a lot pain for longer than she needed to have been.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the need for hospital x-ray after suspected unwitnessed falls
Wider context from the report “9. If there had been a suspicion of an unwitnessed fall, there ought to have been a realisation that an x-ray at the hospital was the only definitive and safe pathway to appropriate treatment , as opposed to examination by a nurse or GP .
” 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 Consider extending tier-two dementia training to all staff across health and care settings.
Verbatim wording from the response “The Dementia 2020 Challenge, which is a programme of action to deliver sustained improvements in dementia care, set the expectation that social care providers deliver appropriate training on dementia to all relevant staff by 2020 to improve the care of people with the condition. As part of the implementation of the Dementia 2020 Challenge, we are considering how best to extend Tier two training to all staff across health and care settings.” Source location 2018-0103-Response-by-Department-of-Health
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 Commission and publish a tiered dementia education and training framework defining essential skills for health and social care staff.
Verbatim wording from the response “On the matter of dementia training specifically, to support a consistent approach to dementia education and training, we commissioned Skills for Health and Health Education England to develop a Core Skills Education and Training Framework. Published in October 2015⁷, the Framework, which sets out the essential skills and knowledge needed for all staff working with people with dementia in health and social care settings, is structured in three tiers, or levels of training, to reflect the different levels of knowledge specific roles would require.” Source location 2018-0103-Response-by-Department-of-Health
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 Individual employers are responsible for ensuring staff are appropriately trained and competent for their roles.
Verbatim wording from the response “I should also point out that it is the responsibility of individual employers to ensure that their staff are appropriately trained and competent to fulfil the responsibilities of the role.” Source location 2018-0103-Response-by-Department-of-Health
Open published response
1 Apr 2018 Julia Jane MacPherson · Prevention of Future Deaths report South London
View report summary
Concerns raised 6 Failure to follow NICE guidelines for prescribing off-licence medicines View source Failure to provide timely clinical review following reported deterioration View source Failure of hospital staff to regularly read clinical and nursing entries in patient medical records View source Failure to formally review mental capacity to consent to treatment View source Absence of a statutory process for recording informal patients' consent to medication View source Incomplete or missing records of consent discussions for off-licence mental health medication View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Julia Jane MacPherson · 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
Julia Jane MacPherson, an informal patient of Oxleas NHS Foundation Trust, suffered swallowing difficulties and collapsed in the community with food bolus and vomitus in her throat; resuscitation was unsuccessful. Concerns included failure to arrange or undertake a timely medical review, failure to assess her mental capacity after concerns about confusion, incomplete clinical records, and prescribing and consent processes for off-licence medication. The inquest recorded the medical cause of death as upper airway obstruction associated with swallowing difficulties secondary to medication-related extrapyramidal symptoms.
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 follow NICE guidelines for prescribing off-licence medicines
Wider context from the report “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however:
(a) This review did not take place and her Responsible Clinician did not see this note until the inquest.
(b) Julia was not reviewed on 16th May.
(c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May.
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records.
(3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised.
(4) NICE guidelines for the prescription of off licenced medicines was not followed.
(5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely clinical review following reported deterioration
Wider context from the report “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however:
(a) This review did not take place and her Responsible Clinician did not see this note until the inquest.
(b) Julia was not reviewed on 16th May .
(c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May.
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records.
(3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised.
(4) NICE guidelines for the prescription of off licenced medicines was not followed.
(5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 hospital staff to regularly read clinical and nursing entries in patient medical records
Wider context from the report “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however:
(a) This review did not take place and her Responsible Clinician did not see this note until the inquest.
(b) Julia was not reviewed on 16th May.
(c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May.
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records .
(3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised.
(4) NICE guidelines for the prescription of off licenced medicines was not followed.
(5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to formally review mental capacity to consent to treatment
Wider context from the report “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however:
(a) This review did not take place and her Responsible Clinician did not see this note until the inquest.
(b) Julia was not reviewed on 16th May.
(c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May.
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records.
(3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised.
(4) NICE guidelines for the prescription of off licenced medicines was not followed.
(5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 statutory process for recording informal patients' consent to medication
Wider context from the report “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however:
(a) This review did not take place and her Responsible Clinician did not see this note until the inquest.
(b) Julia was not reviewed on 16th May.
(c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May.
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records.
(3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised.
(4) NICE guidelines for the prescription of off licenced medicines was not followed.
(5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Incomplete or missing records of consent discussions for off-licence mental health medication
Wider context from the report “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however:
(a) This review did not take place and her Responsible Clinician did not see this note until the inquest.
(b) Julia was not reviewed on 16th May.
(c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May.
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records.
(3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised.
(4) NICE guidelines for the prescription of off licenced medicines was not followed.
(5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients.
” Open source report
27 Mar 2018 Matthew Gayle · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 2 Failure to undertake histology when toxicology is not expected to establish the cause of death View source Insufficient availability and capacity of consultant histopathologists to carry out coroners’ autopsies 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
Matthew Gayle · 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
Matthew Gayle, a serving prisoner at HMP Oakwood, was found dead in his cell on 8 December 2016. The precise cause of death could not be determined, although it was considered likely to have been naturally occurring. The report raised concerns that histology had not been carried out during the post-mortem and about the availability, training, appointment, contractual arrangements and fees of consultant histopathologists undertaking coroners’ autopsies.
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 undertake histology when toxicology is not expected to establish the cause of death
Wider context from the report “Histopathology is very important for determining causes of deaths and it can play a significant role in preventing deaths in the future. When Matthew was found dead he had some illicit drug paraphernalia in one of his hands. He was a young man and the immediate suspicion was that this was a drug related death. The pathologist who conducted the autopsy examined Matthew’s body and took samples for toxicology. Toxicology was carefully carried out (including checking for new psychoactive substances) and the result was that there was nothing in Matthew’s system likely to have caused his death. No histology had been carried out because it was anticipated that toxicology would provide answers. Possibly if histology had been carried out it may have produced a more accurate cause of death for Matthew.
I would make it clear that I do not seek to criticise the pathologist in this respect. You will be aware that there are a declining number of consultant histopathologists who are prepared to carry out autopsies for Coroners and many of those who still perform that function are working under substantial pressure. It is important for the proper investigation of death and the prevention of future deaths that there are sufficient histopathologists to carry out autopsies for Coroner when these are required. I would greatly appreciate your assistance with the following:
1. Are active steps being taken to increase the number of consultant histopathologists who will carry out autopsies for Coroners?
2. Will it be a compulsory part of training of doctors who wish to become histopathologists that they do have experience in Coroners’ autopsies?
3. When engaging consultant histopathologists will NHS Trusts appoint doctors who are both competent and willing to carry out autopsies for Coroners?
4. When appointing consultant histopathologists will NHS Trusts ensure that their contractual arrangements enable them to have time to carry out Coroners’ autopsies?
5. Is there any move to increase the fees payable to consultant histopathologists for carrying out Coroners’ autopsies?
6. Are any steps being taken to progress the Hutton report in establishing specialist centres for histopathology?
7. Are you able to provide me with details of any consultant histopathologists who are prepared to carry out autopsies in the large geographical area that I cover?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 and capacity of consultant histopathologists to carry out coroners’ autopsies
Wider context from the report “Histopathology is very important for determining causes of deaths and it can play a significant role in preventing deaths in the future. When Matthew was found dead he had some illicit drug paraphernalia in one of his hands. He was a young man and the immediate suspicion was that this was a drug related death. The pathologist who conducted the autopsy examined Matthew’s body and took samples for toxicology. Toxicology was carefully carried out (including checking for new psychoactive substances) and the result was that there was nothing in Matthew’s system likely to have caused his death. No histology had been carried out because it was anticipated that toxicology would provide answers. Possibly if histology had been carried out it may have produced a more accurate cause of death for Matthew.
I would make it clear that I do not seek to criticise the pathologist in this respect. You will be aware that there are a declining number of consultant histopathologists who are prepared to carry out autopsies for Coroners and many of those who still perform that function are working under substantial pressure . It is important for the proper investigation of death and the prevention of future deaths that there are sufficient histopathologists to carry out autopsies for Coroner when these are required . I would greatly appreciate your assistance with the following:
1. Are active steps being taken to increase the number of consultant histopathologists who will carry out autopsies for Coroners?
2. Will it be a compulsory part of training of doctors who wish to become histopathologists that they do have experience in Coroners’ autopsies?
3. When engaging consultant histopathologists will NHS Trusts appoint doctors who are both competent and willing to carry out autopsies for Coroners?
4. When appointing consultant histopathologists will NHS Trusts ensure that their contractual arrangements enable them to have time to carry out Coroners’ autopsies?
5. Is there any move to increase the fees payable to consultant histopathologists for carrying out Coroners’ autopsies?
6. Are any steps being taken to progress the Hutton report in establishing specialist centres for histopathology?
7. Are you able to provide me with details of any consultant histopathologists who are prepared to carry out autopsies in the large geographical area that I cover?
” Open source report
20 Mar 2018 Peter O’Donnell · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 9 Failure to document communication and escalation procedures View source Failure to mandate prompt reporting of nurses’ professional misconduct to the Nursing and Midwifery Council View source Failure of private hospitals to adhere to the same reporting requirements as NHS hospitals View source Insufficient post-operative medical staffing capacity View source Failure to maintain contemporaneous and accurate nursing records View source Failure of the private hospital to monitor and appraise Resident Medical Officers View source Lack of protocols and procedures for transferring unwell patients to acute hospitals View source Lack of formal criteria for calling an independent consultant to review patients View source Unclear responsibility for Resident Medical Officer training View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter O’Donnell · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter O’Donnell was admitted for an elective right total hip replacement and later developed a chest infection and deteriorated. The report identifies concerns about ineffective communication, irregular observations, inadequate documentation, delayed antibiotics, missed opportunities to escalate care, unclear consultant and junior doctor arrangements, and the absence of transfer protocols for unwell patients. It also raises concerns about private hospitals’ reporting requirements and the reporting of nurses’ retrospective additions to clinical records.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to document communication and escalation procedures
Wider context from the report “1. Whilst an in-patient the care afforded to the deceased was consultant led. The consultant in question was an independent consultant orthopaedic surgeon who confirmed the absence of any formal agreement regarding the criteria in which he would be subsequently called into the hospital to undertake a review of his patient. The consultant maintained that it would be useful to have a document that detailed the circumstances of any future intervention. In the course of the inquest I was handed a copy of a report entitled “No Safety without Liability” written by the Centre for Health and the Public Interest (available at www.chpi.org.uk). Within that report is a recommendation that private hospital companies should directly employ surgeons, anaesthetists and physicians who work at their hospitals and should take on responsibility for monitoring their activities and appraising their performance. In this instance neither communication nor escalation procedures were documented .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 mandate prompt reporting of nurses’ professional misconduct to the Nursing and Midwifery Council
Wider context from the report “5. Following Mr O’Donnell’s death BMI Healthcare on behalf of the Beaumont Hospital instigated a root cause analysis investigation in the course of which it became clear that two registered General Nurses who were involved in the care afforded to Mr O’Donnell made a number of additions to both the observations chart and nursing notes after Mr O’Donnell had been transferred to the acute Hospital in direct contravention of Clause 10.3 within the Code detailing professional standards of practice and behaviour for Nurses and Midwives issued in 2015.
Whilst the BMA instigated its own independent disciplinary investigation I believe that the Nurse’s actions should have been reported forthwith to the Nursing and Midwifery Council as I believe it would be the case in the public sector. Reporting should be mandatory in the private hospital sector .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 hospitals to adhere to the same reporting requirements as NHS hospitals
Wider context from the report “4. Private hospitals should be required to adhere to the same reporting requirements as NHS Hospitals in order to improve the chance of harm to patients being detected.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 post-operative medical staffing capacity
Wider context from the report “2. A single Junior Doctor (Resident Medical Officer) was the sole Clinician providing post-operative care for patients . He was on duty 24/7 and asserted that a daily review of each patient would be adequate (although this would be a minimum and would depend on the condition of the individual patient). Both the monitoring and appraisal of each RMO remained with an outside Employment Agency rather than the private hospital in which they were based. Responsibility for training was similarly unclear.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 contemporaneous and accurate nursing records
Wider context from the report “5. Following Mr O’Donnell’s death BMI Healthcare on behalf of the Beaumont Hospital instigated a root cause analysis investigation in the course of which it became clear that two registered General Nurses who were involved in the care afforded to Mr O’Donnell made a number of additions to both the observations chart and nursing notes after Mr O’Donnell had been transferred to the acute Hospital in direct contravention of Clause 10.3 within the Code detailing professional standards of practice and behaviour for Nurses and Midwives issued in 2015.
Whilst the BMA instigated its own independent disciplinary investigation I believe that the Nurse’s actions should have been reported forthwith to the Nursing and Midwifery Council as I believe it would be the case in the public sector. Reporting should be mandatory in the private hospital sector.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 private hospital to monitor and appraise Resident Medical Officers
Wider context from the report “2. A single Junior Doctor (Resident Medical Officer) was the sole Clinician providing post-operative care for patients. He was on duty 24/7 and asserted that a daily review of each patient would be adequate (although this would be a minimum and would depend on the condition of the individual patient). Both the monitoring and appraisal of each RMO remained with an outside Employment Agency rather than the private hospital in which they were based . Responsibility for training was similarly unclear.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 protocols and procedures for transferring unwell patients to acute hospitals
Wider context from the report “3. Neither protocols nor procedures existed for the transfer of unwell patients to local acute hospitals . Following the death of Mr O’Donnell the Beaumont and local acute Hospital Trust liaised to formulate a proforma document which would detail the rationale for the transfer as well as including all relevant clinical information which would benefit the receiving Hospital. It is by no means certain that such procedures and documentation exist beyond this jurisdiction of Manchester West.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of formal criteria for calling an independent consultant to review patients
Wider context from the report “1. Whilst an in-patient the care afforded to the deceased was consultant led. The consultant in question was an independent consultant orthopaedic surgeon who confirmed the absence of any formal agreement regarding the criteria in which he would be subsequently called into the hospital to undertake a review of his patient . The consultant maintained that it would be useful to have a document that detailed the circumstances of any future intervention. In the course of the inquest I was handed a copy of a report entitled “No Safety without Liability” written by the Centre for Health and the Public Interest (available at www.chpi.org.uk). Within that report is a recommendation that private hospital companies should directly employ surgeons, anaesthetists and physicians who work at their hospitals and should take on responsibility for monitoring their activities and appraising their performance. In this instance neither communication nor escalation procedures were documented.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for Resident Medical Officer training
Wider context from the report “2. A single Junior Doctor (Resident Medical Officer) was the sole Clinician providing post-operative care for patients. He was on duty 24/7 and asserted that a daily review of each patient would be adequate (although this would be a minimum and would depend on the condition of the individual patient). Both the monitoring and appraisal of each RMO remained with an outside Employment Agency rather than the private hospital in which they were based. Responsibility for training was similarly unclear .
” 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 Conduct the Paterson Inquiry into accountability, supervision and professional standards across independent hospitals and the NHS.
Verbatim wording from the response “Also of importance to the matters of concern you raise is the Paterson Inquiry, set up following the conviction of the surgeon Ian Paterson, to learn lessons from Ian Paterson’s malpractice and other past and current practices to enhance the safety and quality of care both in the independent sector and the NHS.” Source location 2018-0201-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The employer is responsible for deciding whether to refer registered nurses or midwives to the NMC, subject to mandatory referral circumstances.
Verbatim wording from the response “Finally, with regard to your last area of concern, pertaining to the referral of registered nurses to the NMC, I can confirm that the NMC’s guidance applies to all employers of nurses and midwives, whether NHS or independent sector. It is for the employer to decide whether to make a referral based on the circumstances of the case. Referrals must always be made if the employer believes the conduct competence, health or character of a nurse or midwife” Source location 2018-0201-Response-by-Department-of-Health
Open published response
15 Mar 2018 Jean Griffiths · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1 Lack of valid prescriptions for supplementary oxygen including target ranges 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
Jean Griffiths · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jean Griffiths died at Salford Royal Hospital on 15 July 2017 after displaying symptoms of Acute Interstitial Pneumonitis; her disconnected oxygen lead did not contribute to her death. The report raised concerns about poor oxygen-prescribing practice and the risk to patient safety when supplementary oxygen is given without a valid prescription and target range, although there was no evidence that this contributed to Jean Griffiths’ death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of valid prescriptions for supplementary oxygen including target ranges
Wider context from the report “1. In the course of the Inquest I heard evidence from ████████ who is a consultant in Respiratory Medicine at Salford Royal Foundation NHS Trust. ████████ referred in his evidence to the British Thoracic Society’s Emergency Oxygen Audit Report relating to a National Audit Period between the 15th August and the 1st November 2015.
2. ████████ stated that the Audit Report revealed a threat to patient safety due to poor prescribing practice in relation to the prescription of oxygen .
3. A key finding of the report was that 42.5% of patients receiving supplementary oxygen had no valid prescription . Without a valid prescription which includes a target range , ████████ stated that there was a danger that patients might be given too little oxygen or too much oxygen and thus be placed at risk of increased mortality.
4. A copy of the relevant Audit Report is attached.
5. ████████ evidence was that the pace of changing this poor prescribing practice needed to increase.
6. Although there was no evidence that Jean Griffiths’ lack of oxygen prescription was in any way causative of or contributory to her death nevertheless this report is submitted with a view to preventing the deaths of other patients who might be at risk.
” Open source report
Concerns raised 3 Lack of consistent and clear prescribing guidance across local and national lists View source Risk of patients obtaining melatonin from unlicensed internet sources View source Failure to communicate with community GPs before discharge about ongoing melatonin prescribing 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
Peter STOJILJKOVIC · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Stojiljkovic was discharged from hospital on 9 June 2017 after being prescribed melatonin and was later found suspended by a ligature at his home on 22 July 2017. The concerns included poor communication between the hospital, GP and Peter about community prescribing, differing prescribing policies, the complexity of prescribing guidance, and the possibility that he would need to obtain melatonin from unlicensed sources. There was also no evidence of communication with the GP before discharge to support a smooth transition into the community.
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 consistent and clear prescribing guidance across local and national lists
Wider context from the report “2. Whilst an in-patient the deceased was prescribed a drug melatonin that was on the Stockport CCG blacklist although not on all GM CCG blacklists . It was unclear why Stockport CCG took a different approach to other CCGs
3. The inquest heard that GPs are faced with a mixture of lists regarding prescribing. National and local. This results in GPs having to negotiate through a complex system when prescribing where there are grey areas that create uncertainty.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 patients obtaining melatonin from unlicensed internet sources
Wider context from the report “4. The deceased was told he would have to source melatonin for himself over the internet if his GP would not prescribe it . This created a risk that he would have to access the drug from unlicensed sources.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 with community GPs before discharge about ongoing melatonin prescribing
Wider context from the report “1. The deceased had been prescribed melatonin whilst an in-patient. The inquest heard that post his discharge communication between the hospital; GP and Mr Stojiljkovic was such that he was unaware that his GP was prepared to prescribe melatonin in the community ;
2. Whilst an in-patient the deceased was prescribed a drug melatonin that was on the Stockport CCG blacklist although not on all GM CCG blacklists. It was unclear why Stockport CCG took a different approach to other CCGs
3. The inquest heard that GPs are faced with a mixture of lists regarding prescribing. National and local. This results in GPs having to negotiate through a complex system when prescribing where there are grey areas that create uncertainty.
4. The deceased was told he would have to source melatonin for himself over the internet if his GP would not prescribe it. This created a risk that he would have to access the drug from unlicensed sources.
5. It was known whilst he was an in-patient that difficulties with prescribing melatonin in the community would arise. There was no evidence of any attempt to communicate with the GP prior to discharge to ensure a smooth discharge into the community.
” Open source report
7 Mar 2018 Venkata Naga Lakshyasi KAGGA · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 11 Lack of national reinforcement of paediatric assessment for young children View source Lack of understanding of button-battery risks among people responsible for small children View source Failure of NHS information-sharing systems to share detailed illness histories beyond the OOH GP service View source Failure to sustain and nationally reinforce the button-battery safety alert View source Failure to follow the policy for children under 5 View source Failure to complete or fully document child assessments View source Lack of POAU audit systems for detecting noncompliance View source Lack of understanding of the risks of subjective assessments in young children View source Failure to follow the POAU system View source Failure to value-check subjective assessments in young children View source Lack of child-resistant safety features for button batteries in commonly used household devices 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
Venkata Naga Lakshyasi KAGGA · 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
Venkata Naga Lakshyasi KAGGA died on 9 July 2017 after a button battery lodged in her oesophagus and caused an oesophageal arterial fistula. Before her death, she was seen by doctors and ambulance staff, but the battery was not identified. Concerns included failures to examine and assess her, non-compliance with ambulance policy for children under five, inadequate information sharing, and limited understanding of the risks posed by button batteries.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national reinforcement of paediatric assessment for young children
Wider context from the report “3. NWAS had a policy in place in relation to children under 5 that was not followed. Work had been carried out within NWAS subsequent to the death to reinforce the importance of young children been seen by paediatricians. Similar work had not occurred 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 Lack of understanding of button-battery risks among people responsible for small children
Wider context from the report “1. The button battery was likely to have come from a remote control. Button batteries once ingested can lead to catastrophic consequences for a child. They are used with increasing frequency in every day household devices which are often easily accessible by children. The remote control had no safety feature to prevent a child having easy access to the battery without the parents knowledge. Risks of button batteries to small children are not widely understood. Whilst there are precautions in place for children’s toys similar precautions are not in place for commonly used household devices, which can easily be accessed by small children.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS information-sharing systems to share detailed illness histories beyond the OOH GP service
Wider context from the report “7. The 111 service obtained detailed accounts of the history of illness. However systems for sharing information across the NHS are such that this information was not shared beyond the OOH GP service .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 sustain and nationally reinforce the button-battery safety alert
Wider context from the report “2. NHS England issued a safety alert across the NHS in December 2014 relating to button batteries. During the inquest it was clear that the impact of that alert had lessened over time across the Trusts involved . The Trusts involved in the inquest had taken steps to highlight and reinforce the safety alert amongst their workforce but no such national work 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 follow the policy for children under 5
Wider context from the report “3. NWAS had a policy in place in relation to children under 5 that was not followed. Work had been carried out within NWAS subsequent to the death to reinforce the importance of young children been seen by paediatricians. Similar work had not occurred nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to complete or fully document child assessments
Wider context from the report “5. The importance of carrying out a full assessment of a child or documenting fully why it was not carried out on 6ᵗʰ July was not recognised by the medical staff involved .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 POAU audit systems for detecting noncompliance
Wider context from the report “4. The Hospital’s POAU did not follow their system on 6th July and the Doctor on 6ᵗʰ July did not undertake an examination. This was not picked up by the Trust until an internal investigation post death. There was not at the time an audit system in place to ensure that systems in the POAU were being complied with. It is unclear if other POAUs will have audit systems to allow them to pick up on noncompliance with a recognised system .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the risks of subjective assessments in young children
Wider context from the report “6. NWAS staff partly based decision making on 9ᵗʰ July on subjective assessment, which was not value checked with those who knew Venkata. The risks around subjective assessments particularly with young children with no basis on which to make a value comparison did not appear to be fully understood.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 follow the POAU system
Wider context from the report “4. The Hospital’s POAU did not follow their system on 6th July and the Doctor on 6ᵗʰ July did not undertake an examination. This was not picked up by the Trust until an internal investigation post death. There was not at the time an audit system in place to ensure that systems in the POAU were being complied with. It is unclear if other POAUs will have audit systems to allow them to pick up on noncompliance with a recognised system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 value-check subjective assessments in young children
Wider context from the report “6. NWAS staff partly based decision making on 9ᵗʰ July on subjective assessment, which was not value checked with those who knew Venkata . The risks around subjective assessments particularly with young children with no basis on which to make a value comparison did not appear to be fully understood.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 child-resistant safety features for button batteries in commonly used household devices
Wider context from the report “1. The button battery was likely to have come from a remote control. Button batteries once ingested can lead to catastrophic consequences for a child. They are used with increasing frequency in every day household devices which are often easily accessible by children. The remote control had no safety feature to prevent a child having easy access to the battery without the parents knowledge. Risks of button batteries to small children are not widely understood. Whilst there are precautions in place for children’s toys similar precautions are not in place for commonly used household devices, which can easily be accessed by small children.
” Open source report
7 Mar 2018 Ms Ivanika Olivari · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 8 Failure to prioritise risk to life in urgent and emergency situations View source Failure to update relevant staff training promptly and audibly View source Department of Health guidance failing to clearly permit leaving messages for patients in urgent and emergency situations View source Failure to attempt patient contact through all available contact phone numbers in urgent and emergency situations View source GMC guidance failing to clearly permit leaving messages for patients in urgent and emergency situations View source Failure to communicate urgent and emergency guidance clarifications to doctors and relevant NHS staff View source Failure to leave answerphone messages enabling patient contact in urgent and emergency situations View source Hospital guidelines failing to reflect required urgent and emergency communication and life-risk priorities View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ms Ivanika Olivari · 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
Ms Ivanika Olivari died on 3 August 2017 at St George’s Hospital after suffering a cardiac arrest at home associated with a malfunctioning pacemaker. The principal concerns were failures to leave a message or use all available contact numbers in an urgent situation, and the need for guidance, policies and staff training to prioritise risk to life and permit appropriate messages to patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise risk to life in urgent and emergency situations
Wider context from the report “3. That in urgent and emergency situations risk to life should be considered the priority .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 update relevant staff training promptly and audibly
Wider context from the report “5. That hospitals and St George's Hospital in particular, should ensure that all relevant staff have their training updated in a prompt and auditable fashion to reflect the concerns raised 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 Department of Health guidance failing to clearly permit leaving messages for patients in urgent and emergency situations
Wider context from the report “7. That the Department of Health also considers its guidance that it issues in relation to such matters, and amend where necessary to ensure that it is clear that messages may be left for patients in urgent and emergency situations .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 attempt patient contact through all available contact phone numbers in urgent and emergency situations
Wider context from the report “2. That doctors should attempt to contact patients via all contact phone numbers that they have access to for patients in urgent and emergency situations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation GMC guidance failing to clearly permit leaving messages for patients in urgent and emergency situations
Wider context from the report “6. That the GMC considers its guidance for doctors and amend where necessary to ensure that it is clear that messages may be left for patients in urgent and emergency situations .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 urgent and emergency guidance clarifications to doctors and relevant NHS staff
Wider context from the report “8. That the GMC and Department of Health both take steps to ensure that the clarifications as outlined above are communicated to all doctors by the GMC and to all relevant staff employed by the NHS by the Department of Health .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to leave answerphone messages enabling patient contact in urgent and emergency situations
Wider context from the report “1. That doctors should leave messages on answerphones for patients to make contact with them in urgent and emergency situations .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Hospital guidelines failing to reflect required urgent and emergency communication and life-risk priorities
Wider context from the report “4. That hospital guidelines and St George’s hospital guidelines in particular , in relation to such matters, should be updated and amended to reflect the above where needed .
” Open source report
2 Mar 2018 Emily Jayne Hartley · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1 Lack of suitable secure therapeutic environments for people with mental health problems in prison View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emily Jayne Hartley · 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
Emily Jayne Hartley, a serving prisoner at HMP New Hall, was found suspended from a torn bed sheet in an out-of-bounds area during exercise on 23 April 2016; her death was confirmed at the scene. Concerns included serious deficiencies in the management, monitoring and recording of self-harm and suicide prevention procedures, weak information sharing and integrated planning, poor supervision, and the lack of a suitable secure therapeutic environment for people with significant mental health problems.
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 suitable secure therapeutic environments for people with mental health problems in prison
Wider context from the report “(1) It became apparent from the evidence of many Prison Officers and Healthcare Workers that Prison was not the appropriate environment for someone with Emily’s mental health problems . The emphasis should have been on treatment but within a secure environment which Prison, with the most well intentioned staff, cannot adequately provide .
(2) Coincidentally ten years ago I heard an Inquest into the death of Petra Blankbsy, also at New Hall Prison. At the conclusion of this inquest I made a recommendation pursuant to what was then Rule 43 of the Coroner’s Rules 1984. I attach a copy of my Rule 43 recommendations which I repeat in every detail in respect of the death of Emily Jayne Hartley. Furthermore I state that a Prison is not the appropriate place to accommodate Emily and that there should be facilities, particularly in the Prison’s female estate, to provide a therapeutic yet secure environment with the emphasis being on treatment .
I repeat ten years later that the Prison’s department and the Department of Health should conduct a collaborative exercise to achieve the provision of suitable, secure, therapeutic environments in order to treat those with mental health problems of the nature of those demonstrated by Petra Blanksby ten years ago and now Emily Jayne Hartley. I would refer you to a paper prepared by “Inquest” entitled Preventing the Deaths of Women in Prison and the Need for an Alternative Approach which was published in June 2013 and also a report by ████████ of a review of Women with Particular Vulnerabilities in the Criminal Justice System.
” 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 Deliver the female-offender personality-disorder strategy, including specialised services, staff development and enhanced community support.
Verbatim wording from the response “A strategy for improving the care and management of female offenders with personality disorders, jointly planned and delivered by HMPPS and NHS England, was implemented in 2013. It increases the availability of, and access to, specialised personality disorder services including a therapeutic community at HMP Send, and supports staff to develop their knowledge, skills and confidence in working with female offenders with personality disorders. The programme also offers enhanced community-based services for female offenders, including the delivery of community-based treatment programmes, specialist case management and mentoring and advocacy services.” Source location 2018-0063-Response-by-HM-Prisons-and-Probation-Service
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 Keep provision for women in custody with mental health problems under review with health colleagues.
Verbatim wording from the response “A considerable amount of valuable work is being done in the area of improving provision of services for women in custody with mental health problems. Please be assured that I am aware of the importance of this issue and will keep it under review, alongside health colleagues, in order to identify any further steps that can be taken to improve work in this area.” Source location 2018-0063-Response-by-HM-Prisons-and-Probation-Service
Open published response
1 Mar 2018 George French Russell · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to seek guidance during rapidly evolving labour situations View source Lack of structured and direct information sharing between hospital and ambulance services View source Lack of paramedic experience in managing footling breech deliveries View source Failure to provide or seek continuing expert support during footling breech deliveries View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
George French Russell · 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
George French Russell was born prematurely at 35 weeks and 1 day following a footling breech birth on 11 January 2017, in poor condition and with severe brain damage. He died on 23 January 2017 after being transferred for neonatal care. Concerns included inadequate information-sharing between services and a lack of sustained expert input during the breech delivery.
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 seek guidance during rapidly evolving labour situations
Wider context from the report “1. During the inquest it became clear that during the telephone conversation between EMAS and George’s mother her labour was rapidly developing. There was no evidence of the call taker seeking guidance on how to deal with a rapidly evolving situation other than to update the ambulance crew who were on route. (EMAS)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 structured and direct information sharing between hospital and ambulance services
Wider context from the report “2. The way in which information was exchanged between Stepping Hill Hospital and EMAS meant that all those involved in making decisions were not in possession of key facts. There was no structure to how information was shared and it was passed 3rd hand .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 paramedic experience in managing footling breech deliveries
Wider context from the report “3. During labour EMAS were present. The paramedics did not have the experience to deal with a footling breech delivery . Expert input was given for a brief period by a registrar but when that conversation terminated there was no further support given or sought.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 or seek continuing expert support during footling breech deliveries
Wider context from the report “3. During labour EMAS were present. The paramedics did not have the experience to deal with a footling breech delivery. Expert input was given for a brief period by a registrar but when that conversation terminated there was no further support given or sought .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operational concerns are for the involved NHS trusts to address.
Verbatim wording from the response “Your report raises several areas of concern which are operational and for the NHS Trusts involved to address.” Source location 2018-0062-Response-by-Department-of-Health
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 HSIB cannot investigate incidents occurring before its establishment because they do not meet its investigation criteria.
Verbatim wording from the response “I am aware that the HSIB has responded to you to advise that, as this incident occurred before its establishment on 1 April 2017, it does not meet the criteria for investigation. Nevertheless, the information provided will assist the HSIB develop a wider picture of safety issues in the NHS and help inform future investigations.” Source location 2018-0062-Response-by-Department-of-Health
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations