24 Nov 2025 Diana Ocean Grant · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Lack of work or review addressing secure mental health unit capacity and associated risk View source Inability of prison healthcare provision to fully meet mental health patients’ needs View source Inability to provide compulsory medication and treatment in prison View source Requirement for pre-planning before secure mental health unit admission View source Insufficient capacity in the secure mental health unit estate View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Diana Ocean Grant · 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
Diana Ocean Grant, who was experiencing a relapse of paranoid schizophrenia and symptoms of psychosis, died in her prison cell after a foreign object became lodged in her upper airway. The report identified concerns about failures and delays in mental health assessment, treatment, information-sharing, observation and prison placement, as well as the limited availability of secure mental health beds for people requiring admission.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of work or review addressing secure mental health unit capacity and associated risk
Wider context from the report “The concern arises in relation to persons who are judged to need immediate admission to a mental health unit for assessment and/or treatment, but who are also judged to need admission to a secure unit because they are dangerous to others, whether by reason of being under arrest for, or charged with, a serious criminal offence or otherwise.
The evidence I received established that, despite changes made since the Deceased’s death, including the recent introduction of NHS England’s “Mental Health Crisis Care for Londoners: London’s Section 136 Pathway and Health Based Place of Safety Specification”, it remains extremely unlikely that such a person will be granted immediate admission to a secure mental health unit. This is principally because of the restricted capacity of the secure mental health unit estate, but also because of an expectation that some element of pre-planning will take place before such an admission occurs.
Consequently, for many persons in the circumstances described above, detention in prison prior to transfer to a secure mental health unit continues to be unavoidable. The evidence I heard at the inquest suggested that although the expectation, in those circumstances, is that transfer from prison to hospital should take place within 28 days, the low availability of beds actually results in transfers taking, on average, as long as 80 to 90 days.
Detention in prison of persons requiring mental health unit admission raises a concern for risk of death. The evidence I heard established that this is because a mental health patient’s needs cannot be fully met in prison, even in a prison’s health care wing. This is by reason of the fact that there is a material difference in the physical environment, the nursing and therapeutic regimes, and the access to psychological and other therapeutic treatments. Further, whilst medication and treatment can be given compulsorily in hospital, that is not the case in prison.
The witness from whom I heard, stated that he was not aware of any work or review currently being undertaken to address the lack of capacity within the secure mental health unit estate or to address how the above risk may be resolved or managed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inability of prison healthcare provision to fully meet mental health patients’ needs
Wider context from the report “The concern arises in relation to persons who are judged to need immediate admission to a mental health unit for assessment and/or treatment, but who are also judged to need admission to a secure unit because they are dangerous to others, whether by reason of being under arrest for, or charged with, a serious criminal offence or otherwise.
The evidence I received established that, despite changes made since the Deceased’s death, including the recent introduction of NHS England’s “Mental Health Crisis Care for Londoners: London’s Section 136 Pathway and Health Based Place of Safety Specification”, it remains extremely unlikely that such a person will be granted immediate admission to a secure mental health unit. This is principally because of the restricted capacity of the secure mental health unit estate, but also because of an expectation that some element of pre-planning will take place before such an admission occurs.
Consequently, for many persons in the circumstances described above, detention in prison prior to transfer to a secure mental health unit continues to be unavoidable. The evidence I heard at the inquest suggested that although the expectation, in those circumstances, is that transfer from prison to hospital should take place within 28 days, the low availability of beds actually results in transfers taking, on average, as long as 80 to 90 days.
Detention in prison of persons requiring mental health unit admission raises a concern for risk of death. The evidence I heard established that this is because a mental health patient’s needs cannot be fully met in prison, even in a prison’s health care wing . This is by reason of the fact that there is a material difference in the physical environment, the nursing and therapeutic regimes, and the access to psychological and other therapeutic treatments . Further, whilst medication and treatment can be given compulsorily in hospital, that is not the case in prison.
The witness from whom I heard, stated that he was not aware of any work or review currently being undertaken to address the lack of capacity within the secure mental health unit estate or to address how the above risk may be resolved or managed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inability to provide compulsory medication and treatment in prison
Wider context from the report “The concern arises in relation to persons who are judged to need immediate admission to a mental health unit for assessment and/or treatment, but who are also judged to need admission to a secure unit because they are dangerous to others, whether by reason of being under arrest for, or charged with, a serious criminal offence or otherwise.
The evidence I received established that, despite changes made since the Deceased’s death, including the recent introduction of NHS England’s “Mental Health Crisis Care for Londoners: London’s Section 136 Pathway and Health Based Place of Safety Specification”, it remains extremely unlikely that such a person will be granted immediate admission to a secure mental health unit. This is principally because of the restricted capacity of the secure mental health unit estate, but also because of an expectation that some element of pre-planning will take place before such an admission occurs.
Consequently, for many persons in the circumstances described above, detention in prison prior to transfer to a secure mental health unit continues to be unavoidable. The evidence I heard at the inquest suggested that although the expectation, in those circumstances, is that transfer from prison to hospital should take place within 28 days, the low availability of beds actually results in transfers taking, on average, as long as 80 to 90 days.
Detention in prison of persons requiring mental health unit admission raises a concern for risk of death. The evidence I heard established that this is because a mental health patient’s needs cannot be fully met in prison, even in a prison’s health care wing. This is by reason of the fact that there is a material difference in the physical environment, the nursing and therapeutic regimes, and the access to psychological and other therapeutic treatments. Further, whilst medication and treatment can be given compulsorily in hospital, that is not the case in prison .
The witness from whom I heard, stated that he was not aware of any work or review currently being undertaken to address the lack of capacity within the secure mental health unit estate or to address how the above risk may be resolved or managed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Requirement for pre-planning before secure mental health unit admission
Wider context from the report “The concern arises in relation to persons who are judged to need immediate admission to a mental health unit for assessment and/or treatment, but who are also judged to need admission to a secure unit because they are dangerous to others, whether by reason of being under arrest for, or charged with, a serious criminal offence or otherwise.
The evidence I received established that, despite changes made since the Deceased’s death, including the recent introduction of NHS England’s “Mental Health Crisis Care for Londoners: London’s Section 136 Pathway and Health Based Place of Safety Specification”, it remains extremely unlikely that such a person will be granted immediate admission to a secure mental health unit. This is principally because of the restricted capacity of the secure mental health unit estate, but also because of an expectation that some element of pre-planning will take place before such an admission occurs .
Consequently, for many persons in the circumstances described above, detention in prison prior to transfer to a secure mental health unit continues to be unavoidable. The evidence I heard at the inquest suggested that although the expectation, in those circumstances, is that transfer from prison to hospital should take place within 28 days, the low availability of beds actually results in transfers taking, on average, as long as 80 to 90 days.
Detention in prison of persons requiring mental health unit admission raises a concern for risk of death. The evidence I heard established that this is because a mental health patient’s needs cannot be fully met in prison, even in a prison’s health care wing. This is by reason of the fact that there is a material difference in the physical environment, the nursing and therapeutic regimes, and the access to psychological and other therapeutic treatments. Further, whilst medication and treatment can be given compulsorily in hospital, that is not the case in prison.
The witness from whom I heard, stated that he was not aware of any work or review currently being undertaken to address the lack of capacity within the secure mental health unit estate or to address how the above risk may be resolved or managed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity in the secure mental health unit estate
Wider context from the report “The concern arises in relation to persons who are judged to need immediate admission to a mental health unit for assessment and/or treatment, but who are also judged to need admission to a secure unit because they are dangerous to others, whether by reason of being under arrest for, or charged with, a serious criminal offence or otherwise.
The evidence I received established that, despite changes made since the Deceased’s death, including the recent introduction of NHS England’s “Mental Health Crisis Care for Londoners: London’s Section 136 Pathway and Health Based Place of Safety Specification”, it remains extremely unlikely that such a person will be granted immediate admission to a secure mental health unit . This is principally because of the restricted capacity of the secure mental health unit estate , but also because of an expectation that some element of pre-planning will take place before such an admission occurs.
Consequently, for many persons in the circumstances described above, detention in prison prior to transfer to a secure mental health unit continues to be unavoidable. The evidence I heard at the inquest suggested that although the expectation, in those circumstances, is that transfer from prison to hospital should take place within 28 days, the low availability of beds actually results in transfers taking, on average, as long as 80 to 90 days .
Detention in prison of persons requiring mental health unit admission raises a concern for risk of death. The evidence I heard established that this is because a mental health patient’s needs cannot be fully met in prison, even in a prison’s health care wing. This is by reason of the fact that there is a material difference in the physical environment, the nursing and therapeutic regimes, and the access to psychological and other therapeutic treatments. Further, whilst medication and treatment can be given compulsorily in hospital, that is not the case in prison.
The witness from whom I heard, stated that he was not aware of any work or review currently being undertaken to address the lack of capacity within the secure mental health unit estate or to address how the above risk may be resolved or managed.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing local actions are considered appropriate to address the healthcare issues identified at HMP Bronzefield.
Verbatim wording from the response “NHS England has advised that, since April 2023, its South East Health and Justice team has commissioned the full healthcare provision at HMP Bronzefield, including primary care, substance misuse and mental health services. An independent review of healthcare provision at the prison was completed and submitted to the Prisons and Probation Ombudsman in February 2023, and an action plan was subsequently developed with the provider to address the findings. NHS England has confirmed that the London Region is satisfied that appropriate actions have been taken locally in response to the issues identified at inquest.” Source location Response from Department of Health and Social Care
Open published response
18 Nov 2025 Jack Richard BROWN · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 3 Failure of care homes to ensure agency carers' suitability, experience and training View source Absence of a reporting route for concerns about care agencies View source Lack of regulatory inspection of care agency recruitment processes 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
Jack Richard BROWN · 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
Jack Richard BROWN, aged 86, was found unresponsive and died at a care home on 26 January 2023 after remaining asleep on a toilet overnight; the post-mortem examination concluded that he died due to ischemic heart disease. The report raised concerns that care agencies supplying staff to care and nursing homes are not required to register with or be regulated by the CQC or another body, creating risks around recruitment, suitability and training of agency carers.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of care homes to ensure agency carers' suitability, experience and training
Wider context from the report “At the inquest the court heard evidence that care agencies who provide agency care staff to care / nursing homes do not need to register with the CQC and are not regulated by any other body. The activities of such agencies are therefore not inspected or checked to ensure that they have rigorous recruitment processes and there is no one to report matters to when a concern is identified.
This gives rise to a concern as care homes may rely on agencies to vet agency carers and have minimal input into suitability and training for the role . This creates a risk that agency care staff, who may be wholly unsuitable for the role, are providing care to vulnerable people without basic checks as to experience and suitability . This places service users at risk of harm and gives rise to a risk that future deaths could occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of a reporting route for concerns about care agencies
Wider context from the report “At the inquest the court heard evidence that care agencies who provide agency care staff to care / nursing homes do not need to register with the CQC and are not regulated by any other body. The activities of such agencies are therefore not inspected or checked to ensure that they have rigorous recruitment processes and there is no one to report matters to when a concern is identified .
This gives rise to a concern as care homes may rely on agencies to vet agency carers and have minimal input into suitability and training for the role. This creates a risk that agency care staff, who may be wholly unsuitable for the role, are providing care to vulnerable people without basic checks as to experience and suitability. This places service users at risk of harm and gives rise to a risk that future deaths could occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory inspection of care agency recruitment processes
Wider context from the report “At the inquest the court heard evidence that care agencies who provide agency care staff to care / nursing homes do not need to register with the CQC and are not regulated by any other body . The activities of such agencies are therefore not inspected or checked to ensure that they have rigorous recruitment processes and there is no one to report matters to when a concern is identified.
This gives rise to a concern as care homes may rely on agencies to vet agency carers and have minimal input into suitability and training for the role. This creates a risk that agency care staff, who may be wholly unsuitable for the role, are providing care to vulnerable people without basic checks as to experience and suitability. This places service users at risk of harm and gives rise to a risk that future deaths could occur.
” 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 Launch the Adult Social Care Learning and Development Support Scheme to fund eligible care staff courses and qualifications, including the Level 2 Adult Social Care Certificate.
Verbatim wording from the response “The department also launched the Adult Social Care Learning and Development Support Scheme in September 2024, backed by up to £12 million this financial year for eligible care staff to undertake courses and qualifications, including the new Level 2 Adult Social Care Certificate. Developed from the Care Certificate standards, the Level 2 Adult Social Care” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch the Quality Assured Care Learning Service to help individuals and employers identify trusted sector learning and development opportunities.
Verbatim wording from the response “Certificate has been designed to support people in care roles to have the most up to date knowledge and baseline skills required to support people to succeed in their roles. To ensure training undertaken is of good quality, we also launched the Quality Assured Care Learning Service which supports individuals and employers to easily identify trusted learning and development opportunities which meet the needs of the sector.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise and expand the Care Workforce Pathway to provide a national structure for adult social care knowledge, skills, values, behaviours and progression.
Verbatim wording from the response “Further to those regulatory safeguards, the department is committed to enhancing the skills of staff working in adult social care, including those employed by agencies. It is vital to ensure that the care provided is of good quality, fair, personalised, and accessible. The department is supporting the professionalisation of the workforce through a range of activities which agencies can access for their employees. We recently revised and expanded the Care Workforce Pathway, the first national career structure for adult social care. This sets out the knowledge, skills, values, and behaviours needed to work in the sector and provides a framework for progression and development.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing CQC registration requirements, staffing duties, training, supervision and regulatory action provide safeguards for agency staff suitability and competence.
Verbatim wording from the response “Care homes and nursing homes do typically carry out regulated activity and therefore are registered with CQC. CQC requires all health and social care providers registered with them to deploy enough suitably qualified, competent and experienced staff (including both registered and unregistered professionals) to enable them to meet all other regulatory requirements described in Regulation 18 Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These regulations apply to providers who recruit care staff via employment agencies. It is the responsibility of the regulated provider to ensure robust and safe recruitment practices are in place, and to make sure that all staff, including agency staff, are suitably experienced, competent and able to carry out their role.” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Regulated care providers, rather than employment agencies, are responsible for ensuring agency staff are suitably experienced, competent and recruited safely.
Verbatim wording from the response “Care homes and nursing homes do typically carry out regulated activity and therefore are registered with CQC. CQC requires all health and social care providers registered with them to deploy enough suitably qualified, competent and experienced staff (including both registered and unregistered professionals) to enable them to meet all other regulatory requirements described in Regulation 18 Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These regulations apply to providers who recruit care staff via employment agencies. It is the responsibility of the regulated provider to ensure robust and safe recruitment practices are in place, and to make sure that all staff, including agency staff, are suitably experienced, competent and able to carry out their role.” Source location Response from Department for Health and Social Care
Open published response
14 Nov 2025 Suzanne Julia ELLERBY · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Lack of universal guidance for timely primary care follow-up of vulnerable mental health patients transferred from secondary services View source Lack of safety-netting arrangements for timely primary care follow-up of vulnerable mental health patients transferred from secondary services View source Failure of secondary mental health services to ensure primary care follow-up has been undertaken after transfer 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
Suzanne Julia ELLERBY · 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
Suzanne Ellerby was found deceased at her father’s home in Addlestone, Surrey, on 4 January 2025, after a period of mental health deterioration and no contact with mental health or medical practitioners since 13 December 2024. The principal concern was the transfer of vulnerable patients from secondary mental health services to primary care without universal guidance, safety-netting, or arrangements to ensure timely follow-up, leaving patients responsible for arranging care themselves.
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 universal guidance for timely primary care follow-up of vulnerable mental health patients transferred from secondary services
Wider context from the report “Surrey and Borders and Madeira Medical Practice have both recognised the risk of the transfer period from secondary to primary mental health care in vulnerable patients, and have put in hand changes within their organisations to address this. However, as highlighted by Madeira Medical Practice: “there is no expectation from NHS England or mental health services to following up these patients urgently ”, and therefore no universal guidance for all mental health trusts and GP practices .
There are no safety netting guidelines or policies in place to ensure vulnerable mental health patients are followed up within a timely period by primary care services on transfer from secondary services, nor expectations on secondary services to ensure this has been undertaken by primary care services. Patients are therefore being relied upon to ensure this takes place, at a time when they are particularly vulnerable.
- Vulnerable patients are often transferred back to primary care by mental health services for their onward care, which is effected by way of a Discharge Letter;
- NHS England has not provided any guidance in respect of expectation for follow up by primary care services when this transfer takes place ;
- In the absence of such guidance, the onus is on vulnerable patients to ensure they follow up their care with their GP, without any safety netting in place should they fail to do so.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 safety-netting arrangements for timely primary care follow-up of vulnerable mental health patients transferred from secondary services
Wider context from the report “Surrey and Borders and Madeira Medical Practice have both recognised the risk of the transfer period from secondary to primary mental health care in vulnerable patients, and have put in hand changes within their organisations to address this. However, as highlighted by Madeira Medical Practice: “there is no expectation from NHS England or mental health services to following up these patients urgently”, and therefore no universal guidance for all mental health trusts and GP practices.
There are no safety netting guidelines or policies in place to ensure vulnerable mental health patients are followed up within a timely period by primary care services on transfer from secondary services , nor expectations on secondary services to ensure this has been undertaken by primary care services. Patients are therefore being relied upon to ensure this takes place, at a time when they are particularly vulnerable.
- Vulnerable patients are often transferred back to primary care by mental health services for their onward care, which is effected by way of a Discharge Letter;
- NHS England has not provided any guidance in respect of expectation for follow up by primary care services when this transfer takes place;
- In the absence of such guidance, the onus is on vulnerable patients to ensure they follow up their care with their GP, without any safety netting in place should they fail to do so .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of secondary mental health services to ensure primary care follow-up has been undertaken after transfer
Wider context from the report “Surrey and Borders and Madeira Medical Practice have both recognised the risk of the transfer period from secondary to primary mental health care in vulnerable patients, and have put in hand changes within their organisations to address this. However, as highlighted by Madeira Medical Practice: “there is no expectation from NHS England or mental health services to following up these patients urgently”, and therefore no universal guidance for all mental health trusts and GP practices.
There are no safety netting guidelines or policies in place to ensure vulnerable mental health patients are followed up within a timely period by primary care services on transfer from secondary services, nor expectations on secondary services to ensure this has been undertaken by primary care services . Patients are therefore being relied upon to ensure this takes place, at a time when they are particularly vulnerable.
- Vulnerable patients are often transferred back to primary care by mental health services for their onward care, which is effected by way of a Discharge Letter;
- NHS England has not provided any guidance in respect of expectation for follow up by primary care services when this transfer takes place;
- In the absence of such guidance, the onus is on vulnerable patients to ensure they follow up their care with their GP, without any safety netting in place should they fail to do so.
” Open source report
Concerns raised 4 Failure to provide written instructions including safety netting advice after consultation View source Failure to provide face-to-face consultations by a doctor View source Lack of a recognised lower threshold for hospital admission for patients with learning disability View source Failure to make post-consultation instructions understandable and actionable to non-medically trained staff View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jacqueline Aarons · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jacqueline Aarons died at her care home on 19 November 2024 from the consequences of a strangulated umbilical hernia, following vomiting and deterioration over approximately two days. The substantive concerns were the need for a lower threshold for hospital admission for patients with learning disability, face-to-face medical consultation, and clear written safety-netting instructions for care-home staff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide written instructions including safety netting advice after consultation
Wider context from the report “Concern that there should be a recognised lower threshold for hospital admission for patients with learning disability
There should be a fact to face consultation by a doctor.
Following any consultation there should be written instructions including safety netting advice , set out in such a way that they may be understood and acted upon by staff who may not be medically trained.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 face-to-face consultations by a doctor
Wider context from the report “Concern that there should be a recognised lower threshold for hospital admission for patients with learning disability
There should be a fact to face consultation by a doctor.
Following any consultation there should be written instructions including safety netting advice, set out in such a way that they may be understood and acted upon by staff who may not be medically trained.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a recognised lower threshold for hospital admission for patients with learning disability
Wider context from the report “Concern that there should be a recognised lower threshold for hospital admission for patients with learning disability
There should be a fact to face consultation by a doctor.
Following any consultation there should be written instructions including safety netting advice, set out in such a way that they may be understood and acted upon by staff who may not be medically trained.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to make post-consultation instructions understandable and actionable to non-medically trained staff
Wider context from the report “Concern that there should be a recognised lower threshold for hospital admission for patients with learning disability
There should be a fact to face consultation by a doctor.
Following any consultation there should be written instructions including safety netting advice, set out in such a way that they may be understood and acted upon by staff who may not be medically trained .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for addressing the concerns about hospital admission thresholds, in-person consultations and safety-netting advice.
Verbatim wording from the response “In considering your report, officials within the Department of Health and Social Care have made enquiries with NHS England and concluded that these concerns are more appropriately addressed by NHS England directly. I am advised that NHS England will therefore provide you with a full and comprehensive response on the concerns you have raised.” Source location Response from Department for Health and Social Care
Open published response
10 Nov 2025 Unnamed deceased persons · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 5 Failure to routinely monitor formalin in mortuaries View source Lack of appreciation across mortuaries of the dangers posed by formalin to mortuary users View source Lack of availability of appropriate equipment for handling bodies significantly contaminated with formalin View source Frequent receipt of bodies preserved in formalin by mortuaries View source Failure to use appropriate equipment when handling bodies significantly contaminated with formalin View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Unnamed deceased persons · 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
Following an aircraft crash on 12 June 2025, the remains of deceased persons were repatriated to Westminster Public Mortuary wrapped and saturated with high concentrations of formalin. Dangerously high levels of formalin, carbon monoxide and cyanide were detected when coffins were opened and bodies were unwrapped. The report raises concerns about under-appreciation of formalin’s risks in mortuaries, the lack of routine monitoring, and the possible unavailability or non-use of appropriate protective equipment.
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 routinely monitor formalin in mortuaries
Wider context from the report “3. That formalin is not routinely monitored in mortuaries .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 appreciation across mortuaries of the dangers posed by formalin to mortuary users
Wider context from the report “1. There is an under appreciation across mortuaries of the dangers posed by formalin to the health of all mortuary users .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 availability of appropriate equipment for handling bodies significantly contaminated with formalin
Wider context from the report “4. That as such appropriate equipment may not be available nor used when mortuaries handle bodies significantly contaminated with formalin, thus exposing users of mortuaries to health risks including risk of death as outlined above in box 4.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Frequent receipt of bodies preserved in formalin by mortuaries
Wider context from the report “2. That mortuaries frequently receive bodies preserved in formalin .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 appropriate equipment when handling bodies significantly contaminated with formalin
Wider context from the report “4. That as such appropriate equipment may not be available nor used when mortuaries handle bodies significantly contaminated with formalin , thus exposing users of mortuaries to health risks including risk of death as outlined above in box 4.
” Open source report
5 Nov 2025 Jennifer Cahill and Agnes Cahill · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 15 Lack of specialist commissioning of home birth services View source Failure to personalise and individualise pregnancy and birth risk assessment View source Failure to routinely provide women with community midwives’ delivery experience View source Unavailability or significant delay of required interventions during high-risk home births View source Lack of national data collection on home birth transfers, outcomes and out-of-guidance care View source Omission of maternal death risk from intrapartum guidance View source Inconsistent models of home birth care View source Failure to discuss maternal and neonatal death risk with women considering home birth View source Lack of national guidance on home birth care View source Lack of a national framework for safe home birth eligibility and midwifery practice View source Lack of mandated delivery experience requirements for midwives maintaining registration View source Lack of national guidance on staffing, training and experience for home birth midwives View source Use of pregnancy terminology that obscures stage-specific risk View source Lack of bespoke training needs analysis for home birth team midwives View source Lack of national guidance on the ethical responsibility and proportionality of offering home birth under the NHS View source See 12 more concerns
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AI-generated summary
Jennifer Cahill and Agnes Cahill · 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
Jennifer Cahill died in hospital on 4 June 2024 after post-partum haemorrhage, a fourth-degree perineal tear and cardiac arrest following a home birth. Her daughter, Agnes Cahill, was born on 2 June 2024, required resuscitation after complications during birth, and died in neonatal intensive care on 7 June 2024. The report identified concerns including failures in antenatal planning, fetal monitoring, resuscitation and post-birth care, as well as the absence of national guidance and a robust framework for supporting higher-risk home births.
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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 Lack of specialist commissioning of home birth services
Wider context from the report “3. The lack of national guidance means there are differing models of care and unlike other specialities home births are not a specialist commissioned service . There is no national guidance considering the ethical responsibility and proportionality of offering a home birth model under the NHS framework.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 personalise and individualise pregnancy and birth risk assessment
Wider context from the report “6. Terminology around pregnancies describes them as ‘high’ or ‘low risk pregnancy’ and leads women to consider that pregnancy encompasses all stages through to delivery of a child. Practice does not personalise or individualise risk so women can fully understand what the level of risk is for them in actually being pregnant, or what the level of risk is for them in giving birth .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely provide women with community midwives’ delivery experience
Wider context from the report “7. In order to maintain their skills, there is no set number of deliveries a community midwife must conduct following qualification. There is no mandated number of deliveries that any midwife (irrespective of the settings in which they are working) must complete once they have qualified as a midwife in order to maintain their registration. The level of experience of community midwives in conducting deliveries is not information routinely provided to women to inform their decision whether to have a homebirth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 or significant delay of required interventions during high-risk home births
Wider context from the report “2. There is an increase in the number of women with ‘high risk pregnancies’ requesting home births where required interventions cannot take place or would be significantly delayed and there is no robust framework for midwives supporting home birth care. There is no national guidance to support consistent practice across the country including, for example, details of clinical scenarios where women, following robust assessment, have been considered too high risk to safely receive care in a home-setting.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 data collection on home birth transfers, outcomes and out-of-guidance care
Wider context from the report “9. The lack of national data collection means there is no data to evidence the number of women who are transferred in during labour or after birth, maternal or neonatal outcomes, number of women who are considered out of guidance .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Omission of maternal death risk from intrapartum guidance
Wider context from the report “5. NICE guidance on intrapartum care (2023 updated June 2025) Section 1.3.3 only refers to the potential risk of death to a baby . There is no mention in the guidance of risk to the mother .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 models of home birth care
Wider context from the report “3. The lack of national guidance means there are differing models of care and unlike other specialities home births are not a specialist commissioned service. There is no national guidance considering the ethical responsibility and proportionality of offering a home birth model under the NHS framework.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 discuss maternal and neonatal death risk with women considering home birth
Wider context from the report “4. Even though there is a very small risk of death, this is not something which is discussed with women particularly in relation to maternal death , even if the woman has a recognised risk such as a post-partum haemorrhage. There is no guidance to ensure the risk of death to both mother and baby is discussed with any woman considering a home birth irrespective of being considered high or low risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on home birth care
Wider context from the report “1. There is no national guidance in respect of home births . Specifically, robust evidenced based guidance on home birth care , similar to that which is in place for intrapartum care in a hospital setting.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 national framework for safe home birth eligibility and midwifery practice
Wider context from the report “2. There is an increase in the number of women with ‘high risk pregnancies’ requesting home births where required interventions cannot take place or would be significantly delayed and there is no robust framework for midwives supporting home birth care . There is no national guidance to support consistent practice across the country including, for example, details of clinical scenarios where women, following robust assessment, have been considered too high risk to safely receive care in a home-setting .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 mandated delivery experience requirements for midwives maintaining registration
Wider context from the report “7. In order to maintain their skills, there is no set number of deliveries a community midwife must conduct following qualification . There is no mandated number of deliveries that any midwife (irrespective of the settings in which they are working) must complete once they have qualified as a midwife in order to maintain their registration. The level of experience of community midwives in conducting deliveries is not information routinely provided to women to inform their decision whether to have a homebirth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on staffing, training and experience for home birth midwives
Wider context from the report “10. The no national guidance on the model of staffing, training and experience for midwives providing home birth care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Use of pregnancy terminology that obscures stage-specific risk
Wider context from the report “6. Terminology around pregnancies describes them as ‘high’ or ‘low risk pregnancy’ and leads women to consider that pregnancy encompasses all stages through to delivery of a child . Practice does not personalise or individualise risk so women can fully understand what the level of risk is for them in actually being pregnant, or what the level of risk is for them in giving birth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of bespoke training needs analysis for home birth team midwives
Wider context from the report “8. No bespoke training needs analysis has been conducted focusing on midwives practicing in home birth teams .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on the ethical responsibility and proportionality of offering home birth under the NHS
Wider context from the report “3. The lack of national guidance means there are differing models of care and unlike other specialities home births are not a specialist commissioned service. There is no national guidance considering the ethical responsibility and proportionality of offering a home birth model under the NHS framework .
” 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 the ethical proportionality of offering homebirths and discuss with NHS England what further guidance Trusts need.
Verbatim wording from the response “You have raised an important issue relating to the ethical responsibility and proportionality of offering, and women choosing, a homebirth. It is an incredibly personal choice for women about how they wish to give birth and they have a legal right to choose what healthcare they need. I want to acknowledge that women can choose an unsupported homebirth if they wish which carries a greater risk to the women and the baby. I agree that we need to consider this matter closely and will discuss with NHS England what further guidance is needed to better support Trusts manage these finely balanced situations. My officials will also engage with NICE to amend their intrapartum guidance to reflect the risk of maternal death.” Source location Response from Department of Health and Social Care
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PFD Monitor interpretation Approve funding for a neonatal resuscitation training programme covering clinicians’ roles and out-of-hospital homebirth scenarios.
Verbatim wording from the response “Last year, the Department of Health and Social Care approved funding for a new neonatal resuscitation training programme. This training will be specific to the roles and responsibilities for clinicians and the out of hospital course includes homebirth scenarios. Whilst NHS England commissioned the Resuscitation Council UK to update their Neonatal Life Support course, the out of hospital course is now available to staff in all Trusts.” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage with NICE to amend intrapartum guidance to reflect the risk of maternal death.
Verbatim wording from the response “You have raised an important issue relating to the ethical responsibility and proportionality of offering, and women choosing, a homebirth. It is an incredibly personal choice for women about how they wish to give birth and they have a legal right to choose what healthcare they need. I want to acknowledge that women can choose an unsupported homebirth if they wish which carries a greater risk to the women and the baby. I agree that we need to consider this matter closely and will discuss with NHS England what further guidance is needed to better support Trusts manage these finely balanced situations. My officials will also engage with NICE to amend their intrapartum guidance to reflect the risk of maternal death.” Source location Response from Department of Health and Social Care
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Join Nursing and Midwifery Council discussions on post-registration standards for midwives.
Verbatim wording from the response “You raised matters relating to the proficiency, training and skills of midwives in homebirths. The Nursing and Midwifery Council are responsible for setting the proficiencies midwives need to practice, ensuring they have the right skills, knowledge and expertise to safely support women and babies. They are mapping these proficiencies against previous maternity reviews and investigations to better understand where standards need to be strengthened. The Department welcomes, and will join, discussions with the Nursing Midwifery Council relating to post registration standards, whilst noting that the number of deliveries is not alone, a reliable criterion for assessing a midwife’s overall fitness to practice.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The number of deliveries alone is not a reliable criterion for assessing a midwife’s overall fitness to practise.
Verbatim wording from the response “You raised matters relating to the proficiency, training and skills of midwives in homebirths. The Nursing and Midwifery Council are responsible for setting the proficiencies midwives need to practice, ensuring they have the right skills, knowledge and expertise to safely support women and babies. They are mapping these proficiencies against previous maternity reviews and investigations to better understand where standards need to be strengthened. The Department welcomes, and will join, discussions with the Nursing Midwifery Council relating to post registration standards, whilst noting that the number of deliveries is not alone, a reliable criterion for assessing a midwife’s overall fitness to practice.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trusts are responsible for ensuring maternity care is delivered in line with Nursing and Midwifery Council standards.
Verbatim wording from the response “I wholeheartedly agree that all risks throughout pregnancy, particularly the risk of death to both the mother and baby, must be discussed sensitively and fully with women. Whilst this is important for every woman regardless of the level of risk associated with the pregnancy, it is even more critical for women who identified as high risk. I am deeply sorry that for Jennifer, this did not happen, and we must ensure this does not happen again. The Nursing and Midwifery Council has guidance for midwives to support informed decision making, principles for supporting women’s choices throughout their maternity care and for outside of hours care. It is the responsibility of Trusts to ensure care is delivered in line with these standards.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Nursing and Midwifery Council is responsible for setting the proficiencies required for midwives to practise safely.
Verbatim wording from the response “You raised matters relating to the proficiency, training and skills of midwives in homebirths. The Nursing and Midwifery Council are responsible for setting the proficiencies midwives need to practice, ensuring they have the right skills, knowledge and expertise to safely support women and babies. They are mapping these proficiencies against previous maternity reviews and investigations to better understand where standards need to be strengthened. The Department welcomes, and will join, discussions with the Nursing Midwifery Council relating to post registration standards, whilst noting that the number of deliveries is not alone, a reliable criterion for assessing a midwife’s overall fitness to practice.” Source location Response from Department of Health and Social Care
Open published response
28 Oct 2025 Lewis Aubrey GARFIELD · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 7 Delays in transferring patients from the Emergency Department into wards View source Failure to provide interim safety guidance while awaiting ambulance arrival View source Delays in ambulance-to-hospital handover View source Delays in medically trained clinician review of ambulance call information View source Delays in transferring ambulance patients into the Emergency Department View source Failure to adequately record and accurately and completely convey symptom information View source Failure to base triage category changes on evidence of clinical change or deterioration View source See 4 more concerns
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AI-generated summary
Lewis Aubrey GARFIELD · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lewis Aubrey Garfield suffered an intracerebral haemorrhage at home on 4 December 2024, fell down the stairs, and was taken to John Radcliffe Hospital, where he died on 8 December 2024. Concerns included delays in clinical review and ambulance attendance, inadequate guidance to the family while awaiting an ambulance, and delays handing patients over from ambulances to hospitals, with wider delays affecting patient flow and ambulance availability.
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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 transferring patients from the Emergency Department into wards
Wider context from the report “f) The delays getting patients from the Emergency Department (ED) into wards , causes delays taking patients from ambulances into ED, and a knock-on delay getting ambulances back out into the community. These delays persist despite the current actions to mitigate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 interim safety guidance while awaiting ambulance arrival
Wider context from the report “c) The family complained of not being given any guidance on how to deal with the patient pending the arrival of an ambulance e.g. not to move him given the fall down the stairs .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance-to-hospital handover
Wider context from the report “d) I understand that nationally, the target time for handover from ambulance to hospital staff is 15 minutes. In the present case, the handover from ambulance to nursing staff at John Radcliffe Hospital took 25 minutes. However, at the same time, the longest handover time at Northampton General Hospital was 5 hours and at Kettering General Hospital it was 7 hours . The Trust lost 115 hours waiting to handover at Northampton over 121 hours at Kettering.
e) I heard evidence that steps are being taken to mitigate the impact of pressures in the healthcare system. University Hospitals of Northamptonshire have adopted the ‘45-minute handover’ approach. Despite this, on the day of the inquest on 27 October 2025, average handover times at Northampton General Hospital were 1 hour 11 minutes and I suspect that this will get worse during the full onset of winter pressures.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 medically trained clinician review of ambulance call information
Wider context from the report “b) The first call was at around 00:44 hours but it was not until over 4 hours later at 05:05 hrs that a medically trained clinician first reviewed the facts , immediately escalating it to category 1.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring ambulance patients into the Emergency Department
Wider context from the report “f) The delays getting patients from the Emergency Department (ED) into wards, causes delays taking patients from ambulances into ED , and a knock-on delay getting ambulances back out into the community. These delays persist despite the current actions to mitigate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately record and accurately and completely convey symptom information
Wider context from the report “a) It was not clear if information about the symptoms taken by SCAS was adequate or if it had been recorded or conveyed by them accurately/completely. It was odd that the call was upgraded to category 2, just 14 minutes after being designated a category 3, without any evidence that there had been a change or deterioration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 base triage category changes on evidence of clinical change or deterioration
Wider context from the report “a) It was not clear if information about the symptoms taken by SCAS was adequate or if it had been recorded or conveyed by them accurately/completely. It was odd that the call was upgraded to category 2, just 14 minutes after being designated a category 3, without any evidence that there had been a change or deterioration.
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase staffing to mitigate seasonal urgent and emergency care pressures.
Verbatim wording from the response “Regarding your concerns for the upcoming winter, we have implemented additional surge capacity, increased staffing, and enhanced coordination across services to mitigate seasonal pressures. This includes running stress test exercises and offering health checks to the most vulnerable.” Source location Response from Department for Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reduce ambulance handovers to a maximum of 45 minutes and average Category 2 response times to 30 minutes.
Verbatim wording from the response “We are taking serious steps to achieve this. We published our Urgent and Emergency Care Plan for 2025/26 which focuses on improvements to deliver better UEC performance both daily and during winter pressures, ensuring more patients receive timely and clinically appropriate care. Key actions include:” Source location Response from Department for Health and Social Care
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve hospital patient flow, increase four-hour emergency-department performance to 78%, reduce 12-hour waits and tackle discharge delays.
Verbatim wording from the response “We are taking serious steps to achieve this. We published our Urgent and Emergency Care Plan for 2025/26 which focuses on improvements to deliver better UEC performance both daily and during winter pressures, ensuring more patients receive timely and clinically appropriate care. Key actions include:” Source location Response from Department for Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enable ambulance services to convey patients directly to non-emergency-department facilities, including same-day emergency care services.
Verbatim wording from the response “We are taking serious steps to achieve this. We published our Urgent and Emergency Care Plan for 2025/26 which focuses on improvements to deliver better UEC performance both daily and during winter pressures, ensuring more patients receive timely and clinically appropriate care. Key actions include:” Source location Response from Department for Health and Social Care
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement additional winter surge capacity across urgent and emergency care services.
Verbatim wording from the response “Regarding your concerns for the upcoming winter, we have implemented additional surge capacity, increased staffing, and enhanced coordination across services to mitigate seasonal pressures. This includes running stress test exercises and offering health checks to the most vulnerable.” Source location Response from Department for Health and Social Care
Open published response
Concerns raised 7 Excessive and prolonged holding of people in mental health crisis in A&E View source Failure to answer a sufficient proportion of 111 and Blue Light Line calls View source Lack of a safe lawful detention pathway for people who cannot be held under s.3 at the hospital View source Failure of A&E environments to provide adequate security for people in mental health crisis View source Inadequate 24/7 crisis response and formal gatekeeping of inpatient admissions View source Insufficient availability of independent-sector mental health beds View source Failure to divert people in mental health crisis to suitable alternatives to A&E where available View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Patricia Genders · 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 Genders died on 22 February 2024 after absconding from the Enhanced Observation Unit at the Royal Sussex County Hospital while detained under the Mental Health Act. She was found on the coastal side of a safety fence, taken to A&E, and pronounced dead shortly afterwards. The concerns included the use of A&E for people in mental health crisis, the absence of an agreed home-care package, the decision not to transport Patricia to a more therapeutic setting, and shortcomings in hospital security, communication and responses to absconding.
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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 Excessive and prolonged holding of people in mental health crisis in A&E
Wider context from the report “My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement . My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long .
This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury's conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure. People are coming and going; doors cannot always be monitored; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around.
Tricia was able, quite easily, to abscond. The detail of what happened next, and its impact on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and fireman at the cliffs.
All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all). All this, however, is just patching a fundamentally unsatisfactory situation.
I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern.
The evidence I heard is that three things are required of those responsible for commissioning these services:
1. Strengthening the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available. At the moment, I was told, only about half of those calls are answered. That requires recruitment, which requires investment.
2. An improved 24/7 crisis response, to deal with those who present at A&E out of hours. Solving that requires the establishment of teams who can formally gatekeep inpatient admissions.
3. For a while, there will need to be an increase in the number of mental health beds available in the independent sector. This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds.
Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 answer a sufficient proportion of 111 and Blue Light Line calls
Wider context from the report “My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement. My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long.
This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury's conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure. People are coming and going; doors cannot always be monitored; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around.
Tricia was able, quite easily, to abscond. The detail of what happened next, and its impact on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and fireman at the cliffs.
All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all). All this, however, is just patching a fundamentally unsatisfactory situation.
I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern.
The evidence I heard is that three things are required of those responsible for commissioning these services:
1. Strengthening the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available. At the moment, I was told, only about half of those calls are answered . That requires recruitment, which requires investment.
2. An improved 24/7 crisis response, to deal with those who present at A&E out of hours. Solving that requires the establishment of teams who can formally gatekeep inpatient admissions.
3. For a while, there will need to be an increase in the number of mental health beds available in the independent sector. This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds.
Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 safe lawful detention pathway for people who cannot be held under s.3 at the hospital
Wider context from the report “My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement. My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long.
This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury's conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure. People are coming and going; doors cannot always be monitored; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around.
Tricia was able, quite easily, to abscond. The detail of what happened next, and its impact on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and fireman at the cliffs.
All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all ). All this, however, is just patching a fundamentally unsatisfactory situation.
I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern.
The evidence I heard is that three things are required of those responsible for commissioning these services:
1. Strengthening the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available. At the moment, I was told, only about half of those calls are answered. That requires recruitment, which requires investment.
2. An improved 24/7 crisis response, to deal with those who present at A&E out of hours. Solving that requires the establishment of teams who can formally gatekeep inpatient admissions.
3. For a while, there will need to be an increase in the number of mental health beds available in the independent sector. This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds.
Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of A&E environments to provide adequate security for people in mental health crisis
Wider context from the report “My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement. My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long.
This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury's conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure . People are coming and going; doors cannot always be monitored ; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around .
Tricia was able, quite easily, to abscond . The detail of what happened next, and its impact on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and fireman at the cliffs.
All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all). All this, however, is just patching a fundamentally unsatisfactory situation.
I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern.
The evidence I heard is that three things are required of those responsible for commissioning these services:
1. Strengthening the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available. At the moment, I was told, only about half of those calls are answered. That requires recruitment, which requires investment.
2. An improved 24/7 crisis response, to deal with those who present at A&E out of hours. Solving that requires the establishment of teams who can formally gatekeep inpatient admissions.
3. For a while, there will need to be an increase in the number of mental health beds available in the independent sector. This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds.
Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 24/7 crisis response and formal gatekeeping of inpatient admissions
Wider context from the report “My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement. My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long.
This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury's conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure. People are coming and going; doors cannot always be monitored; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around.
Tricia was able, quite easily, to abscond. The detail of what happened next, and its impact on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and fireman at the cliffs.
All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all). All this, however, is just patching a fundamentally unsatisfactory situation.
I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern.
The evidence I heard is that three things are required of those responsible for commissioning these services:
1. Strengthening the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available. At the moment, I was told, only about half of those calls are answered. That requires recruitment, which requires investment.
2. An improved 24/7 crisis response, to deal with those who present at A&E out of hours . Solving that requires the establishment of teams who can formally gatekeep inpatient admissions .
3. For a while, there will need to be an increase in the number of mental health beds available in the independent sector. This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds.
Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of independent-sector mental health beds
Wider context from the report “My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement. My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long.
This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury's conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure. People are coming and going; doors cannot always be monitored; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around.
Tricia was able, quite easily, to abscond. The detail of what happened next, and its impact on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and fireman at the cliffs.
All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all). All this, however, is just patching a fundamentally unsatisfactory situation.
I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern.
The evidence I heard is that three things are required of those responsible for commissioning these services:
1. Strengthening the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available. At the moment, I was told, only about half of those calls are answered. That requires recruitment, which requires investment.
2. An improved 24/7 crisis response, to deal with those who present at A&E out of hours. Solving that requires the establishment of teams who can formally gatekeep inpatient admissions.
3. For a while, there will need to be an increase in the number of mental health beds available in the independent sector . This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds.
Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 divert people in mental health crisis to suitable alternatives to A&E where available
Wider context from the report “My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement. My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long.
This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury's conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure. People are coming and going; doors cannot always be monitored; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around.
Tricia was able, quite easily, to abscond. The detail of what happened next, and its impact on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and fireman at the cliffs.
All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all). All this, however, is just patching a fundamentally unsatisfactory situation.
I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern.
The evidence I heard is that three things are required of those responsible for commissioning these services:
1. Strengthening the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available . At the moment, I was told, only about half of those calls are answered. That requires recruitment, which requires investment.
2. An improved 24/7 crisis response, to deal with those who present at A&E out of hours. Solving that requires the establishment of teams who can formally gatekeep inpatient admissions.
3. For a while, there will need to be an increase in the number of mental health beds available in the independent sector. This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds.
Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur.
” 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 Transform neighbourhood mental health services to shift crisis care from hospitals to communities.
Verbatim wording from the response “Your second recommendation highlighted the need for improved 24/7 crisis response, to deal with those who present at A&E out of hours. Our 10 Year Health Plan sets out ambitious plans to create up to 85 mental health emergency departments as alternatives to A&E for people in crisis and transform neighbourhood mental health services to shift the focus from hospital to community.” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deploy mental health professionals in 999 emergency operation centres and clinical assessment services.
Verbatim wording from the response “The introduction of a ‘mental health’ option when calling NHS 111 provides a crisis mental health triage service for individuals who require urgent mental health support. To supplement the NHS 111 mental health crisis triage service, we are also deploying mental health professionals in 999 call emergency operation centres and clinical assessment services to ensure people experiencing a mental health crisis are directed towards appropriate services. We continue to increase mental health expertise for ambulance” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest in local urgent and emergency mental health infrastructure, including crisis cafes, crisis houses, places of safety, emergency departments and crisis lines.
Verbatim wording from the response “There has also been investment into a range of wider local mental health urgent and emergency care infrastructure schemes, including:” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fund and roll out specialised mental health ambulances staffed by physical and mental healthcare professionals.
Verbatim wording from the response “Funding has also been provided for specialised mental health ambulances which are being rolled out across the country. The mental health vehicles will be staffed by both physical and mental healthcare professionals trained to deliver support on-scene or to transfer people to the most appropriate place for care.” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed mental health professionals in ambulance emergency operation centres.
Verbatim wording from the response “The introduction of a ‘mental health’ option when calling NHS 111 provides a crisis mental health triage service for individuals who require urgent mental health support. To supplement the NHS 111 mental health crisis triage service, we are also deploying mental health professionals in 999 call emergency operation centres and clinical assessment services to ensure people experiencing a mental health crisis are directed towards appropriate services. We continue to increase mental health expertise for ambulance” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a mental health crisis option through NHS 111.
Verbatim wording from the response “In relation to strengthening the 111 and Blue Light Line services, I understand you were informed that only about half of the calls are answered. We are working hard to ensure those experiencing mental health crisis receive swift care in the most appropriate setting and we have made substantial progress, including introducing the mental health option via NHS 111 and expanding 24/7 liaison mental health teams to all general acute hospitals.” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand 24/7 liaison mental health teams to all general acute hospitals.
Verbatim wording from the response “In relation to strengthening the 111 and Blue Light Line services, I understand you were informed that only about half of the calls are answered. We are working hard to ensure those experiencing mental health crisis receive swift care in the most appropriate setting and we have made substantial progress, including introducing the mental health option via NHS 111 and expanding 24/7 liaison mental health teams to all general acute hospitals.” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create up to 85 mental health emergency departments as alternatives to A&E.
Verbatim wording from the response “Your second recommendation highlighted the need for improved 24/7 crisis response, to deal with those who present at A&E out of hours. Our 10 Year Health Plan sets out ambitious plans to create up to 85 mental health emergency departments as alternatives to A&E for people in crisis and transform neighbourhood mental health services to shift the focus from hospital to community.” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual trusts and local health systems are responsible for assessing and managing local mental health bed capacity.
Verbatim wording from the response “Regarding your concern on a need for an increase in the number of mental health beds available in the independent sector. Individual trusts and local health systems are responsible for effectively assessing and managing local bed capacity through the ‘flow’ of patients being discharged or moving to another setting. The NHS Operational Planning Guidance for 2025-26 contains fewer targets across the board to focus on the fundamentals of good care. It sets a requirement for Integrated Care Boards to take action to reduce the average length of stay in adult acute mental health beds, improving local bed availability and reducing the need for inappropriate out of area placement, and to reduce waits longer than 12 hours in A&E.” Source location Response from Department for Health and Social Care
Open published response
24 Oct 2025 Sophie Louise TOWLE · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 12 Lack of policy prompts for cross-sector consultation in foreign-body cases View source Lack of clarity about the current personality disorder service and level of provision View source Lack of staff working knowledge of the current local VTE policy View source Absence of a specialised central personality disorder service View source Failure of the foreign-object insertion policy to require mental health consultation View source Insufficient staffing capacity on mental health wards View source Insufficient experience across the mental health ward staff pool View source Ineffective communication of foreign-object insertion policy and guidance to staff View source Insufficient or ineffective training on the VTE policy View source Lack of an embedded mechanism for cross-sector MDT meetings and liaison in foreign-body cases View source Failure of the local VTE policy to provide clear, robust and consistent assessment requirements View source Lack of specific, clear and robust policy guidance for managing foreign-object insertion View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sophie Louise TOWLE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sophie Louise TOWLE died at Kings Mill Hospital on 27 May 2024 after suffering a large pulmonary embolus originating from a deep vein thrombosis in her left leg. The report describes concerns about the management of an inserted foreign object, VTE risk assessment and related policy and training, mental health services for patients with personality disorders, staffing levels, and cross-sector communication and working.
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 policy prompts for cross-sector consultation in foreign-body cases
Wider context from the report “1. Lack of joint agency policy/cross-sector working between physical and mental health trusts in relation to the insertion of foreign bodies
I heard evidence that it would have been beneficial in Sophie’s case for there to have been an MDT between Sophie’s psychiatric team (NHCT) and her physical health team (Orthopaedics and Anaesthesia at SFH). The reason that this would have been of assistance is due to the complexity of cases where there are physical and mental health considerations in play for decisions around the management of a foreign body.
There is no embedded mechanism for arranging MDT meetings, or indeed for any liaison or contact between these teams, in such cases. Similarly, there is no policy or procedure which prompts clinicians from either team to consider an MDT in these cases or, at the very least, picking up the phone for a consult.
If this had happened in Sophie’s case, it seems likely that the outcome in relation to the management of the foreign body would have been different. Sophie’s psychiatric team were keen for removal and were satisfied that they could implement a robust policy to avoid re-insertion, which was one of the main concerns of the Orthopaedic team.
In my opinion there is a risk that future deaths could occur unless action is taken in relation to this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the current personality disorder service and level of provision
Wider context from the report “3. The disbanding of the Personality Disorder Hub at NHCT
I am told that as of mid-October 2025, the Personality Disorder Hub at NHCT has been disbanded. Neither the witness who worked within the disbanded service, nor the policy witness for NHCT was able to give me any particulars as to the arrangement of the new service, beyond a general statement that it was being absorbed into the LMHTs. I was told by the witness who had worked within the PDH that his understanding for his LMHT was that there would be a personality disorder service which would consist of him, as that was his specialist interest.
Given the current inquiry into Mental Health Services in Nottinghamshire, and particularly the care of those patients with personality disorders within the service, I am concerned about the lack of clarity within the Trust as to the current position and level of service available to patients with personality disorders.
I am concerned that an absence of a specialised and central service dealing with personality disorder patients, with care provided by specialists in personality disorder, causes a risk of future death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of staff working knowledge of the current local VTE policy
Wider context from the report “2. VTE risk assessment and associated policy and training at NHCT
During the course of Sophie’s inquest, I heard evidence which concerns me that there is a lack of clarity in relation to the current local VTE policy. I was provided with version of the policy that I have assured was current at the outset of the inquest. All witnesses who were directly asked about this policy recognised it as the current policy in its terms. On 22 October 2025, I was sent late disclose of the correct updated policy which was ratified in April 2025 (available to view from May 2025), some 6 months before the inquest hearing began. The updated policy was materially different in its terms on the frequency and circumstances in which VTE risk assessments should be undertaken. This gives rise to a number of specific concerns:
A) The staff do not have a proper working knowledge of the current local VTE policy.
B) The knock-on concern from this is that the training around the VTE policy is not robust in its content or is otherwise not being properly engaged with by staff.
C) The current policy has been weakened in its terms, in particular at paragraph 1.6 where the requirement for an updated assessment of risk on at least a weekly basis has been removed. I understand from the evidence that, notwithstanding the wording changes to the policy, prompts are given on VTE risk assessment at the weekly MDTs. I am concerned that the policy is not reflective of the encouraged practice on the Wards. I am also concerned that, whilst this happens on Fir Ward, it is important that guidance is consistent across all wards within the Trust. The common document across the wards is the local policy and therefore I am concerned about the clarity and robustness of its terms.
In my opinion there is a risk that future deaths could occur unless action is taken in relation to this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of a specialised central personality disorder service
Wider context from the report “3. The disbanding of the Personality Disorder Hub at NHCT
I am told that as of mid-October 2025, the Personality Disorder Hub at NHCT has been disbanded. Neither the witness who worked within the disbanded service, nor the policy witness for NHCT was able to give me any particulars as to the arrangement of the new service, beyond a general statement that it was being absorbed into the LMHTs. I was told by the witness who had worked within the PDH that his understanding for his LMHT was that there would be a personality disorder service which would consist of him, as that was his specialist interest.
Given the current inquiry into Mental Health Services in Nottinghamshire, and particularly the care of those patients with personality disorders within the service, I am concerned about the lack of clarity within the Trust as to the current position and level of service available to patients with personality disorders.
I am concerned that an absence of a specialised and central service dealing with personality disorder patients, with care provided by specialists in personality disorder , causes a risk of future death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of the foreign-object insertion policy to require mental health consultation
Wider context from the report “4. The policy and procedures around the management of insertion of foreign objects for SFH
I have had sight of the newly ratified local policy for management of insertion of foreign objects at SFH. I am concerned that its content is lacking in specificity, the language used is vague and open to interpretation, and it does not provide clear advice for medical professionals accessing it for guidance. It is not a robust policy in its terms.
Further, I am concerned that it does not make any reference to consultation of mental health services, whether local or acute, at all. Given that the policy recognises that in the majority of cases where management of insertion of foreign objects the patient has a mental health condition, I find this particularly concerning.
Based on the evidence that I have heard, I am also concerned that there is no effective communication of the policy and guidance to Trust staff on this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing capacity on mental health wards
Wider context from the report “5. Staffing on mental health wards
I have been told by numerous witnesses to this inquest that the staffing levels on Fir Ward both at the time of Sophie’s admission, and now, are insufficient. The result of that, I am told, is that the wards cannot run safely and patient care and safety negatively impacted. Staff simply do not have time to complete essential tasks on the ward (like physical observations, completing care plans and risk assessments etc.) or give the patients the 1:1 time they require. I saw a genuine concern and regret on the faces of the hardworking healthcare professionals who gave evidence in my court of the course of this inquest, some were brought to tears. The job is relentless, and they do not feel supported by virtue of a lack of staff numbers and experience. I am told that this remains the case notwithstanding that the minimum staffing levels as governed by the Department of Health and Social Care are being met. This is an issue of grave concern. It suggests that the minimum levels of staff are too low, the staff pool is not sufficiently experienced across the board, that the wards are not functioning safely and that patients are at risk of death as a result.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 experience across the mental health ward staff pool
Wider context from the report “5. Staffing on mental health wards
I have been told by numerous witnesses to this inquest that the staffing levels on Fir Ward both at the time of Sophie’s admission, and now, are insufficient. The result of that, I am told, is that the wards cannot run safely and patient care and safety negatively impacted. Staff simply do not have time to complete essential tasks on the ward (like physical observations, completing care plans and risk assessments etc.) or give the patients the 1:1 time they require. I saw a genuine concern and regret on the faces of the hardworking healthcare professionals who gave evidence in my court of the course of this inquest, some were brought to tears. The job is relentless, and they do not feel supported by virtue of a lack of staff numbers and experience. I am told that this remains the case notwithstanding that the minimum staffing levels as governed by the Department of Health and Social Care are being met. This is an issue of grave concern. It suggests that the minimum levels of staff are too low, the staff pool is not sufficiently experienced across the board , that the wards are not functioning safely and that patients are at risk of death as a result.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Ineffective communication of foreign-object insertion policy and guidance to staff
Wider context from the report “4. The policy and procedures around the management of insertion of foreign objects for SFH
I have had sight of the newly ratified local policy for management of insertion of foreign objects at SFH. I am concerned that its content is lacking in specificity, the language used is vague and open to interpretation, and it does not provide clear advice for medical professionals accessing it for guidance. It is not a robust policy in its terms.
Further, I am concerned that it does not make any reference to consultation of mental health services, whether local or acute, at all. Given that the policy recognises that in the majority of cases where management of insertion of foreign objects the patient has a mental health condition, I find this particularly concerning.
Based on the evidence that I have heard, I am also concerned that there is no effective communication of the policy and guidance to Trust staff on this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient or ineffective training on the VTE policy
Wider context from the report “2. VTE risk assessment and associated policy and training at NHCT
During the course of Sophie’s inquest, I heard evidence which concerns me that there is a lack of clarity in relation to the current local VTE policy. I was provided with version of the policy that I have assured was current at the outset of the inquest. All witnesses who were directly asked about this policy recognised it as the current policy in its terms. On 22 October 2025, I was sent late disclose of the correct updated policy which was ratified in April 2025 (available to view from May 2025), some 6 months before the inquest hearing began. The updated policy was materially different in its terms on the frequency and circumstances in which VTE risk assessments should be undertaken. This gives rise to a number of specific concerns:
A) The staff do not have a proper working knowledge of the current local VTE policy.
B) The knock-on concern from this is that the training around the VTE policy is not robust in its content or is otherwise not being properly engaged with by staff.
C) The current policy has been weakened in its terms, in particular at paragraph 1.6 where the requirement for an updated assessment of risk on at least a weekly basis has been removed. I understand from the evidence that, notwithstanding the wording changes to the policy, prompts are given on VTE risk assessment at the weekly MDTs. I am concerned that the policy is not reflective of the encouraged practice on the Wards. I am also concerned that, whilst this happens on Fir Ward, it is important that guidance is consistent across all wards within the Trust. The common document across the wards is the local policy and therefore I am concerned about the clarity and robustness of its terms.
In my opinion there is a risk that future deaths could occur unless action is taken in relation to this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of an embedded mechanism for cross-sector MDT meetings and liaison in foreign-body cases
Wider context from the report “1. Lack of joint agency policy/cross-sector working between physical and mental health trusts in relation to the insertion of foreign bodies
I heard evidence that it would have been beneficial in Sophie’s case for there to have been an MDT between Sophie’s psychiatric team (NHCT) and her physical health team (Orthopaedics and Anaesthesia at SFH). The reason that this would have been of assistance is due to the complexity of cases where there are physical and mental health considerations in play for decisions around the management of a foreign body.
There is no embedded mechanism for arranging MDT meetings, or indeed for any liaison or contact between these teams, in such cases. Similarly, there is no policy or procedure which prompts clinicians from either team to consider an MDT in these cases or, at the very least, picking up the phone for a consult.
If this had happened in Sophie’s case, it seems likely that the outcome in relation to the management of the foreign body would have been different. Sophie’s psychiatric team were keen for removal and were satisfied that they could implement a robust policy to avoid re-insertion, which was one of the main concerns of the Orthopaedic team.
In my opinion there is a risk that future deaths could occur unless action is taken in relation to this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of the local VTE policy to provide clear, robust and consistent assessment requirements
Wider context from the report “2. VTE risk assessment and associated policy and training at NHCT
During the course of Sophie’s inquest, I heard evidence which concerns me that there is a lack of clarity in relation to the current local VTE policy. I was provided with version of the policy that I have assured was current at the outset of the inquest. All witnesses who were directly asked about this policy recognised it as the current policy in its terms. On 22 October 2025, I was sent late disclose of the correct updated policy which was ratified in April 2025 (available to view from May 2025), some 6 months before the inquest hearing began. The updated policy was materially different in its terms on the frequency and circumstances in which VTE risk assessments should be undertaken. This gives rise to a number of specific concerns:
A) The staff do not have a proper working knowledge of the current local VTE policy.
B) The knock-on concern from this is that the training around the VTE policy is not robust in its content or is otherwise not being properly engaged with by staff.
C) The current policy has been weakened in its terms, in particular at paragraph 1.6 where the requirement for an updated assessment of risk on at least a weekly basis has been removed. I understand from the evidence that, notwithstanding the wording changes to the policy, prompts are given on VTE risk assessment at the weekly MDTs. I am concerned that the policy is not reflective of the encouraged practice on the Wards. I am also concerned that, whilst this happens on Fir Ward, it is important that guidance is consistent across all wards within the Trust. The common document across the wards is the local policy and therefore I am concerned about the clarity and robustness of its terms.
In my opinion there is a risk that future deaths could occur unless action is taken in relation to this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of specific, clear and robust policy guidance for managing foreign-object insertion
Wider context from the report “4. The policy and procedures around the management of insertion of foreign objects for SFH
I have had sight of the newly ratified local policy for management of insertion of foreign objects at SFH. I am concerned that its content is lacking in specificity, the language used is vague and open to interpretation, and it does not provide clear advice for medical professionals accessing it for guidance. It is not a robust policy in its terms.
Further, I am concerned that it does not make any reference to consultation of mental health services, whether local or acute, at all. Given that the policy recognises that in the majority of cases where management of insertion of foreign objects the patient has a mental health condition, I find this particularly concerning.
Based on the evidence that I have heard, I am also concerned that there is no effective communication of the policy and guidance to Trust staff on this issue.
” 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 Responsibility for local mental health staffing and operations lies with the relevant trust, not the Government.
Verbatim wording from the response “The Government is not able to comment on staffing levels locally, as responsibility for the staffing and operations of mental health services lies with the relevant trust. However, we do recognise the wider need to improve care in NHS mental health services.” Source location Response from Department of Health and Social Care
Open published response
21 Oct 2025 Amber Grace Walker · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 2 Failure to consistently discuss SUDEP with patients with epilepsy View source Lack of SUDEP training for doctors View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Amber Grace Walker · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Amber Grace Walker, who had epilepsy and uncontrolled nocturnal tonic-clonic seizures, was found deceased at home on 19 April 2023. A post-mortem examination identified Sudden Unexpected Death in Epilepsy (SUDEP) as the medical cause of death. The concerns were that SUDEP and Amber’s individual risk, including the implications of declining increased medication, were not discussed with her, and that SUDEP discussions and related training for doctors were not consistent or universal.
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 consistently discuss SUDEP with patients with epilepsy
Wider context from the report “i. Doctors can be reluctant to discuss SUDEP with patients and/or presume it is a discussion that has been had at previous appointments(s) with colleagues that does not need repeating. There are tools, such as the SUDEP Action-produced “SUDEP Checklist”, that can facilitate such a discussion, but they are not used universally. The SUDEP Checklist can be used by any medical practitioner who may come into contact with a patient with epilepsy. Discussions about SUDEP ensure that patients are aware of the general risks of SUDEP, the risks that are specific to the patient and the measures that can be taken to mitigate the risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of SUDEP training for doctors
Wider context from the report “ii. SUDEP is not covered in the medical training of doctors , despite is being the leading cause of death in patients with a diagnosis of epilepsy. It is not only neurologists that will encounter patients with epilepsy where a discussion regarding SUDEP may be required , as demonstrated by Amber’s experience.
” 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 Medical schools, royal colleges and the GMC determine and oversee medical education curricula and standards, rather than the department.
Verbatim wording from the response “In relation to the education and training of doctors, individual medical schools set their own undergraduate medical curriculum. These have to meet the standards set by the General Medical Council (GMC), which monitors and checks to make sure that the standards are maintained.” Source location Response from Department of Health and Social Care
Open published response
17 Oct 2025 OWEN AUSTIN DONNELLY · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Failure to criminalise possession of items enabling weapon construction View source Unrestricted internet access to information enabling construction of weapons View source Proliferation of unlicensed weapons 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
OWEN AUSTIN DONNELLY · 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
OWEN AUSTIN DONNELLY was discovered collapsed and unresponsive in the garden of his residence on 16 February 2025, with a self-inflicted head wound, and was verified dead by attending paramedics. The inquest concluded suicide. Concerns included the ability to research, access, download and use material widely available on the internet, the fact that possession of material enabling construction of such a weapon was not then a criminal offence, and the risk posed while proposed legislation remained under consideration.
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 criminalise possession of items enabling weapon construction
Wider context from the report “1. The deceased was able research, access, download and then to make use of ████████ widely available on the internet, primarily from the United States, ████████
2. The possession of ████████ that can enable an individual to construct a ████████ is not currently a criminal offence .
3. I heard evidence from a ████████ expert that there is an alarming proliferation of ████████ weapons within England and Wales, ████████ ████████ that are unlicensed and therefore increasingly available for criminal or nefarious purposes.
4. A Bill criminalising the possession of such ████████ is awaiting a second reading before Parliament. Until such time proposed legislation is enacted , there remains a real and immediate risk that individuals may access the internet ████████ ████████
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unrestricted internet access to information enabling construction of weapons
Wider context from the report “1. The deceased was able research, access, download and then to make use of ████████ widely available on the internet , primarily from the United States, ████████
2. The possession of ████████ that can enable an individual to construct a ████████ is not currently a criminal offence.
3. I heard evidence from a ████████ expert that there is an alarming proliferation of ████████ weapons within England and Wales, ████████ ████████ that are unlicensed and therefore increasingly available for criminal or nefarious purposes.
4. A Bill criminalising the possession of such ████████ is awaiting a second reading before Parliament. Until such time proposed legislation is enacted, there remains a real and immediate risk that individuals may access the internet ████████ ████████
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Proliferation of unlicensed weapons
Wider context from the report “1. The deceased was able research, access, download and then to make use of ████████ widely available on the internet, primarily from the United States, ████████
2. The possession of ████████ that can enable an individual to construct a ████████ is not currently a criminal offence.
3. I heard evidence from a ████████ expert that there is an alarming proliferation of ████████ weapons within England and Wales , ████████ ████████ that are unlicensed and therefore increasingly available for criminal or nefarious purposes .
4. A Bill criminalising the possession of such ████████ is awaiting a second reading before Parliament. Until such time proposed legislation is enacted, there remains a real and immediate risk that individuals may access the internet ████████ ████████
” Open source report
17 Oct 2025 MELANIE JAYNE WALKER · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Failure to ensure staff awareness and training about current heart-monitor deficiencies View source Failure of heart monitors to alert clinicians to cardiac events View source Failure of heart monitors to re-alert when ECG leads remain disconnected View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
MELANIE JAYNE WALKER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Melanie Jayne Walker, who had a complex medical history and drug and alcohol dependency, was found collapsed and partially responsive on 17 December 2024 and later suffered an unobserved cardiac arrest in hospital. She sustained an irreversible hypoxic brain injury and died on 26 December 2024 after life support was withdrawn. The principal concern was that her heart monitor did not alert staff to the cardiac event, partly because monitoring equipment had become disconnected and the monitor’s alert system did not re-alarm after acknowledgement, creating an ongoing patient-safety risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff awareness and training about current heart-monitor deficiencies
Wider context from the report “1. Whilst the deceased had been fitted with a heart monitor whilst being assessed in the busy Resuscitation Department of the hospital, she experienced a cardiac event that ought to have triggered her hearty monitor to alert clinicians to this medical emergency, in fact, this did not occur.
2. A Patient Safety Incident Investigation (PSII) had been commissioned by the Hospital Trust determined:
a. Where, an untoward event – such as an abnormal reading, or (as in this case) with a monitor lead was inadvertently disconnected, this creates a blue ‘in op’ alert with a ‘bloop’ type sound (as opposed to a continuous alarm) – with the consequence that the ECG lead is unable to detect a reading and is therefore inoperable.
b. The ‘in op’ alert creates a blue banner to alert staff. Once acknowledged (by the staff member pressing the button) this does not re-alert, even if the lead remains disconnected,
c. Accordingly, there is a risk that a lead could remain disconnected, if the reason for the staff pressing ‘acknowledge’ is to acknowledge an abnormal reading.
d. Whilst Royal Bolton Hospital Trust have mitigated the identified patient safety issues and it understood that the manufacturers (Philips) are undertaking to reconfigure their monitors so that when an ECG lead is removed this creates a ‘yellow alert’ that will ensure that the monitor will re-alarm in the scenario of a patient removing the lead when unobserved – the evidence established that this risk remains an issue for other hospital trusts in the interim.
e. Royal Bolton Hospital have identified the need for patients who are deliberately or inadvertently removing monitoring equipment will be the subject of additional support, such as a 1:1 Health Care Assistant.
3. There remains an ongoing concern that until these heart monitoring machines are re-configured, and staff made aware and trained as to their current deficiencies , with no mitigating arrangements in place , that a patient can suffer a fatal cardiac event in any clinical setting and an erroneous assumption made by health care staff that a patient is being appropriately monitored .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 heart monitors to alert clinicians to cardiac events
Wider context from the report “1. Whilst the deceased had been fitted with a heart monitor whilst being assessed in the busy Resuscitation Department of the hospital, she experienced a cardiac event that ought to have triggered her hearty monitor to alert clinicians to this medical emergency, in fact, this did not occur .
2. A Patient Safety Incident Investigation (PSII) had been commissioned by the Hospital Trust determined:
a. Where, an untoward event – such as an abnormal reading, or (as in this case) with a monitor lead was inadvertently disconnected, this creates a blue ‘in op’ alert with a ‘bloop’ type sound (as opposed to a continuous alarm) – with the consequence that the ECG lead is unable to detect a reading and is therefore inoperable.
b. The ‘in op’ alert creates a blue banner to alert staff. Once acknowledged (by the staff member pressing the button) this does not re-alert, even if the lead remains disconnected,
c. Accordingly, there is a risk that a lead could remain disconnected, if the reason for the staff pressing ‘acknowledge’ is to acknowledge an abnormal reading.
d. Whilst Royal Bolton Hospital Trust have mitigated the identified patient safety issues and it understood that the manufacturers (Philips) are undertaking to reconfigure their monitors so that when an ECG lead is removed this creates a ‘yellow alert’ that will ensure that the monitor will re-alarm in the scenario of a patient removing the lead when unobserved – the evidence established that this risk remains an issue for other hospital trusts in the interim.
e. Royal Bolton Hospital have identified the need for patients who are deliberately or inadvertently removing monitoring equipment will be the subject of additional support, such as a 1:1 Health Care Assistant.
3. There remains an ongoing concern that until these heart monitoring machines are re-configured, and staff made aware and trained as to their current deficiencies, with no mitigating arrangements in place, that a patient can suffer a fatal cardiac event in any clinical setting and an erroneous assumption made by health care staff that a patient is being appropriately monitored.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 heart monitors to re-alert when ECG leads remain disconnected
Wider context from the report “1. Whilst the deceased had been fitted with a heart monitor whilst being assessed in the busy Resuscitation Department of the hospital, she experienced a cardiac event that ought to have triggered her hearty monitor to alert clinicians to this medical emergency, in fact, this did not occur.
2. A Patient Safety Incident Investigation (PSII) had been commissioned by the Hospital Trust determined:
a. Where, an untoward event – such as an abnormal reading, or (as in this case) with a monitor lead was inadvertently disconnected, this creates a blue ‘in op’ alert with a ‘bloop’ type sound (as opposed to a continuous alarm) – with the consequence that the ECG lead is unable to detect a reading and is therefore inoperable.
b. The ‘in op’ alert creates a blue banner to alert staff. Once acknowledged (by the staff member pressing the button) this does not re-alert, even if the lead remains disconnected ,
c. Accordingly, there is a risk that a lead could remain disconnected , if the reason for the staff pressing ‘acknowledge’ is to acknowledge an abnormal reading.
d. Whilst Royal Bolton Hospital Trust have mitigated the identified patient safety issues and it understood that the manufacturers (Philips) are undertaking to reconfigure their monitors so that when an ECG lead is removed this creates a ‘yellow alert’ that will ensure that the monitor will re-alarm in the scenario of a patient removing the lead when unobserved – the evidence established that this risk remains an issue for other hospital trusts in the interim .
e. Royal Bolton Hospital have identified the need for patients who are deliberately or inadvertently removing monitoring equipment will be the subject of additional support, such as a 1:1 Health Care Assistant.
3. There remains an ongoing concern that until these heart monitoring machines are re-configured, and staff made aware and trained as to their current deficiencies, with no mitigating arrangements in place, that a patient can suffer a fatal cardiac event in any clinical setting and an erroneous assumption made by health care staff that a patient is being appropriately monitored.
” 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 MHRA is responsible for assessing whether further field safety corrective action or device safety information is necessary.
Verbatim wording from the response “As next steps, MHRA is currently assessing this notice in line with its internal process flow, which includes an Extensive Review of the controls recommended by Philips and a Risk Assessment of the need for any further Field Safety Corrective Action and/or a Device Safety Information Alert. Should further action be found necessary to prevent future harms, I will ensure you are notified.” Source location Response from Department for Health and Social Care
Open published response
13 Oct 2025 Jack Mathew Peatling · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1 Lack of available mental health in-patient beds for very high-risk patients who cannot be safely managed in the community View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jack Mathew Peatling · 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
Jack Mathew Peatling, who had a very high risk of suicide, made further serious suicide attempts and was assessed as requiring urgent inpatient mental health care. No suitable inpatient bed was available for six days, during which he was managed in the community despite clinical recognition that his risk could not be safely managed there; he died by suicide on 5 June 2023. The report identified the chronic lack of available high-risk mental health inpatient beds as a principal concern.
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 available mental health in-patient beds for very high-risk patients who cannot be safely managed in the community
Wider context from the report “(a) A highly vulnerable 20-year-old man, with a history of anxiety, depression and impulsive previous suicide attempts made two further serious attempts to take his own life and inflicted an extensive wound to his arm ████████ after those suicide attempts were frustrated by his mother. The subsequent formal MHA assessment determined Jack to be such a high risk of suicide that an immediate period of assessment and treatment as a (voluntary) in-patient on an MHAU was required as his high risk of suicide could not be safely managed in the community.
(b) No such bed was available over the six days between the MHA assessment and Jack’s suicide with still no indication, at the time of his death, as to if or when a bed would be available. By default, and notwithstanding point (a) above, the HTT, absent an in-patient bed, became responsible for his care in the community.
(c) In his evidence, it was further expressly recognised by the HTT psychiatrist who saw Jack on the 31st May that his “very, very high risk” of suicide at that time could not be managed safely in the community by the HTT and, further, that Jack was “untreatable” in the community.
(d) Nonetheless, and notwithstanding the unanimous clinical view, the non-availability of an EPUT MHAU in-patient bed meant that the HTT were required to attempt to mitigate this unmanageable level of risk in the community, something that the HTT was, as had been anticipated, unable to do.
(e) The evidence confirmed that a lack of available in-patient beds for high-risk mental health patients who, as was acknowledged at the time, cannot be managed safely in the community, is a chronic and on-going situation in Essex and, the inquest was told, nationally.
(f) Jack took his own life by deploying a ligature ████████
████████ on the sixth day awaiting the necessary, required in-patient bed. Had an in-patient bed been made available, he would probably not have died. Jack’s death was avoidable.
(g) Absent the provision of available mental health in-patient beds for very high-risk patients that formal Mental Health Act assessments have clinically determined cannot be managed safely in the community, then further avoidable deaths by suicide amongst this cohort of vulnerable patients appears inevitable.
” 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 Local trusts and health systems are expected to assess and manage local mental-health bed capacity through patient flow.
Verbatim wording from the response “I expect individual trusts and local health systems to effectively assess and manage local bed capacity through the ‘flow’ of patients being discharged or moving to another setting.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 3 Failure to ensure comprehensive cross-service information sharing and coordinated assessment and care View source Failure to ensure in-person mental health assessments where remote appointments are unsuitable View source Lack of policy, protocols and guidance for safeguarding mental health patients with accompanying physical health issues View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sarah Louise Healey · 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
Sarah Louise Healey was admitted to hospital on 4 May 2024 with severe malnutrition and complex infections after longstanding mental health difficulties and a highly restricted diet. She deteriorated and died on 1 August 2024 from respiratory failure secondary to pleural effusions, hypoalbuminaemia and malnutrition. The principal concerns were inadequate, inconsistent and insufficiently joined-up mental health care, information sharing and collaboration, particularly for patients with physical health issues, neurodiversity or difficulty attending in-person appointments.
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 comprehensive cross-service information sharing and coordinated assessment and care
Wider context from the report “Whilst I heard evidence that local Mental Health (MH) Services (the Sussex Partnership Foundation Trust) had aimed to ensure the recognised ‘triangle of care’ (MH Services, Individual and Family) was in place, this did not (and I understand that national policy and approach may not extend to other services such as the GP, private counselling, or e.g. social services being formally involved and engaged in a comprehensive assessment and hence effective package of treatment and care .
I fully appreciate that there are ethical, legal and patient confidentiality issues in patient care. Without, first, better information sharing and a wider, collaborative and joined-up approach – ideally with one individual [whether MH clinician, GP or even carer/family member] able, empowered and with the right legal authority to ensure they have a comprehensive and detailed knowledge of the individual’s various issues – and, second, the development of policy, protocols and guidance to better safeguard mental health patients with accompanying physical health issues, especially those who may have capacity and are neuro-diverse, there is a risk of patients like Sarah not receiving the right, consistent and individually tailored care and treatment which may prevent self-neglect or other serious self-harm.
I also heard evidence that there is, nationally, a move away from traditional in-person or face to face appointments as standard and regular practice, to the increased use of online platforms and tools enabling remote attendance. I completely recognise that there are huge benefits in the use of such systems, which bring savings, efficiency and immediacy of access for a huge number of patients. My concern is that they work for some but not all. I was encouraged by evidence I heard from SPFT that in their development of a Care Plan Approach and the inception of Community Mental Health Teams there will be a local policy requirement for MH Practitioners to see patients in person at least six monthly. Sarah’s case graphically demonstrated that there is no substitute for physically seeing a patient, especially when there are other conditions and lifestyle issues so clearly impacting on or resulting from her mental health, such that it seems that an agreed national approach and similar policy requirement may also further help to prevent future deaths of patients like Sarah.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 in-person mental health assessments where remote appointments are unsuitable
Wider context from the report “Whilst I heard evidence that local Mental Health (MH) Services (the Sussex Partnership Foundation Trust) had aimed to ensure the recognised ‘triangle of care’ (MH Services, Individual and Family) was in place, this did not (and I understand that national policy and approach may not extend to other services such as the GP, private counselling, or e.g. social services being formally involved and engaged in a comprehensive assessment and hence effective package of treatment and care.
I fully appreciate that there are ethical, legal and patient confidentiality issues in patient care. Without, first, better information sharing and a wider, collaborative and joined-up approach – ideally with one individual [whether MH clinician, GP or even carer/family member] able, empowered and with the right legal authority to ensure they have a comprehensive and detailed knowledge of the individual’s various issues – and, second, the development of policy, protocols and guidance to better safeguard mental health patients with accompanying physical health issues, especially those who may have capacity and are neuro-diverse, there is a risk of patients like Sarah not receiving the right, consistent and individually tailored care and treatment which may prevent self-neglect or other serious self-harm.
I also heard evidence that there is, nationally, a move away from traditional in-person or face to face appointments as standard and regular practice, to the increased use of online platforms and tools enabling remote attendance . I completely recognise that there are huge benefits in the use of such systems, which bring savings, efficiency and immediacy of access for a huge number of patients. My concern is that they work for some but not all . I was encouraged by evidence I heard from SPFT that in their development of a Care Plan Approach and the inception of Community Mental Health Teams there will be a local policy requirement for MH Practitioners to see patients in person at least six monthly. Sarah’s case graphically demonstrated that there is no substitute for physically seeing a patient , especially when there are other conditions and lifestyle issues so clearly impacting on or resulting from her mental health, such that it seems that an agreed national approach and similar policy requirement may also further help to prevent future deaths of patients like Sarah .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 policy, protocols and guidance for safeguarding mental health patients with accompanying physical health issues
Wider context from the report “Whilst I heard evidence that local Mental Health (MH) Services (the Sussex Partnership Foundation Trust) had aimed to ensure the recognised ‘triangle of care’ (MH Services, Individual and Family) was in place, this did not (and I understand that national policy and approach may not extend to other services such as the GP, private counselling, or e.g. social services being formally involved and engaged in a comprehensive assessment and hence effective package of treatment and care.
I fully appreciate that there are ethical, legal and patient confidentiality issues in patient care. Without, first, better information sharing and a wider, collaborative and joined-up approach – ideally with one individual [whether MH clinician, GP or even carer/family member] able, empowered and with the right legal authority to ensure they have a comprehensive and detailed knowledge of the individual’s various issues – and, second, the development of policy, protocols and guidance to better safeguard mental health patients with accompanying physical health issues, especially those who may have capacity and are neuro-diverse , there is a risk of patients like Sarah not receiving the right, consistent and individually tailored care and treatment which may prevent self-neglect or other serious self-harm .
I also heard evidence that there is, nationally, a move away from traditional in-person or face to face appointments as standard and regular practice, to the increased use of online platforms and tools enabling remote attendance. I completely recognise that there are huge benefits in the use of such systems, which bring savings, efficiency and immediacy of access for a huge number of patients. My concern is that they work for some but not all. I was encouraged by evidence I heard from SPFT that in their development of a Care Plan Approach and the inception of Community Mental Health Teams there will be a local policy requirement for MH Practitioners to see patients in person at least six monthly. Sarah’s case graphically demonstrated that there is no substitute for physically seeing a patient, especially when there are other conditions and lifestyle issues so clearly impacting on or resulting from her mental health, such that it seems that an agreed national approach and similar policy requirement may also further help to prevent future deaths of patients like Sarah.
” 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 Launch the National Neighbourhood Health Implementation Programme to integrate health and social care teams and improve comprehensive community care.
Verbatim wording from the response “As your report has highlighted, better integration is needed between physical and mental health care provision. Through our 10-Year Health Plan, we are delivering a shift from hospital to community. As part of this, we have launched the National Neighbourhood Health Implementation Programme. Neighbourhood Health Services will bring together teams of professionals closer to people’s home - nurses, doctors, social care workers, mental health professionals and more – to work together to provide comprehensive care in the community. This will support systems across the country by driving innovation and integration at a local level, to accelerate improvements in patient outcomes and satisfaction and ensuring care is more joined-up, accessible, and responsive to community needs.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local services determine the availability of in-person mental health appointments, and no national policy is currently planned.
Verbatim wording from the response “Regarding your concerns around the lack of national policy on conducting face to face appointments, while we aim to deliver a shift from analogue to digital through the 10-Year Health Plan, we recognise that, for some patients, in-person appointments are needed. I understand that community mental health teams often provide face-to-face assessments and follow-up reviews based on individual need, and NHS guidance for mental health services (such as NHS Talking Therapies) states that services should offer a choice of in-person or remotely delivered therapies, although the primary consideration is always the clinical appropriateness of the care, and the clinician’s professional opinion will be central to the decision.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 5 Failure to procure interpreting services through agencies specialising in British Sign Language View source Lack of availability of British Sign Language qualifications and training View source Failure to recruit and retain sufficient BSL-proficient clinicians View source Lack of statutory regulation for British Sign Language interpreters View source Lack of British Sign Language interpreters available to support deaf mental health patients View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Imogen Alice NUNN · 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
Imogen Alice Nunn died at home on 1 January 2023 after consuming a substance she had obtained approximately six weeks earlier, during a period of deteriorating mental health. The report raises concerns about failures in mental-health risk management and the shortage of British Sign Language interpreters and BSL-proficient clinicians supporting deaf 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 procure interpreting services through agencies specialising in British Sign Language
Wider context from the report “1. Matter for the Cabinet Office (Equalities. The Disability Unit/BSL Advisory Board. Sponsoring the Procurement Act 2023.
AND the Minister of State (Minister for Social Security and Disability)
The Chief Executive of the NRCPD provided evidence that the Procurement Act offers NHS bodies and Integrated Care Boards (ICBs) the opportunity to collaborate with organisations like NRCPD to develop contracts that improve the delivery of BSL interpreting services. At present, contracts for interpreting services are often awarded to larger agencies, where BSL interpreting forms only a small part of broader contracts primarily focused on spoken languages, rather than being handled by agencies specialising in BSL. Evidence also highlighted the absence of statutory regulation for BSL interpreters. The NRCPD Chief Executive emphasised that establishing a statutory regulator would help professionalise and elevate the status of BSL interpreters, which in turn would promote the role and increase the number of specialists available to support deaf mental health patients. Since the Cabinet Office holds responsibility for disabilities, I raise these concerns regarding the national shortage of BSL interpreters and the lack of regulation in this area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of availability of British Sign Language qualifications and training
Wider context from the report “3. Matter for the Department of Education.
Evidence was heard that the lack of BSL interpreters was in part due to the lack of availability of BSL qualifications and training .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to recruit and retain sufficient BSL-proficient clinicians
Wider context from the report “2. Department of Health and Social Care
Evidence indicates that clinicians who are fluent in British Sign Language (BSL) provide a significantly better experience for deaf patients compared to non-BSL - speaking clinicians relying solely on interpreters.
The NHS England response to the earlier Prevention of Future Deaths (PFD) report outlined the role of Integrated Care Boards (ICBs) in commissioning interpreting services for NHS Trusts. However, there is a clear shortage of BSL-proficient clinicians , and insufficient efforts are being made to recruit and retain these professionals . This gap is failing to meet the needs of deaf individuals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 statutory regulation for British Sign Language interpreters
Wider context from the report “1. Matter for the Cabinet Office (Equalities. The Disability Unit/BSL Advisory Board. Sponsoring the Procurement Act 2023.
AND the Minister of State (Minister for Social Security and Disability)
The Chief Executive of the NRCPD provided evidence that the Procurement Act offers NHS bodies and Integrated Care Boards (ICBs) the opportunity to collaborate with organisations like NRCPD to develop contracts that improve the delivery of BSL interpreting services. At present, contracts for interpreting services are often awarded to larger agencies, where BSL interpreting forms only a small part of broader contracts primarily focused on spoken languages, rather than being handled by agencies specialising in BSL. Evidence also highlighted the absence of statutory regulation for BSL interpreters. The NRCPD Chief Executive emphasised that establishing a statutory regulator would help professionalise and elevate the status of BSL interpreters, which in turn would promote the role and increase the number of specialists available to support deaf mental health patients. Since the Cabinet Office holds responsibility for disabilities, I raise these concerns regarding the national shortage of BSL interpreters and the lack of regulation in this area .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of British Sign Language interpreters available to support deaf mental health patients
Wider context from the report “It was issued before the Inquest had concluded as it had already become apparent that there was a real lack of British Sign Language Interpreters (BSLs) able to help support Deaf patients in the community who were being treated with mental health difficulties . This was putting this cohort of individuals at risk . The overall lack of British Sign Language Interpreters was also evidenced directly by the Court in that this Inquest has had to be delayed/adjourned for two months due to there being no available Interpreters to interpreter for two deaf/mute witnesses over the two week period of the Inquest.
” Open source report
23 Sep 2025 Tony Buengo Jackson · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Unavailability of notes for the 24th November admission View source Failure to detect iatrogenic injury despite clinical assessment and investigation View source Failure of governance processes to remediate sub-optimal practice View source Poor recording of best interest decisions, PEG insertion and subsequent treatment View source Failure to identify incidents requiring investigation through the Patient Safety Framework View source Failure of governance processes to reflect upon sub-optimal practice View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tony Buengo Jackson · 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
Tony Buengo-Jackson, who had progressive multiple sclerosis and lived in a nursing home, died after a PEG tube inserted on 19 November 2024 passed through his transverse colon, causing bowel perforation, peritonitis and sepsis. The report raises concerns that the injury was not detected until 3 December despite an earlier admission, CT scan and surgical consultation, and that poor records and inadequate Trust governance impeded investigation and learning.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of notes for the 24th November admission
Wider context from the report “3. The Trust could not provide notes of the 24th November admission .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to detect iatrogenic injury despite clinical assessment and investigation
Wider context from the report “1. A fatal iatrogenic injury caused to Tony Buengo-Jackson on 19th November 2024 went undetected until 3rd December 2024 , despite admission, CT scan and surgical consult on 24th November 2024 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of governance processes to remediate sub-optimal practice
Wider context from the report “4. A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice in this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor recording of best interest decisions, PEG insertion and subsequent treatment
Wider context from the report “2. Records of, best interest decisions, the PEG insertion and subsequent treatment were so poor as to impede the court’s investigation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to identify incidents requiring investigation through the Patient Safety Framework
Wider context from the report “4. A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework . This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify , reflect upon, and remediate sub-optimal practice in this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of governance processes to reflect upon sub-optimal practice
Wider context from the report “4. A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon , and remediate sub-optimal practice in this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate .
” 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 Expand Martha’s Rule to all acute inpatient sites.
Verbatim wording from the response “Measures we have taken over the last year include:” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CQC will decide whether further action is needed regarding the Trust’s application of PSIRF.
Verbatim wording from the response “Regarding the concerns about application of the PSIRF, the Trust is reviewing the mortality and morbidity process across the hospital to ensure better alignment with learning and improvement systems. CQC have raised concerns with the Trust that there is disparity in the effective application of PSIRF across the different hospital’s governance teams. The CQC will review the Trust’s response and decide if any further action is needed.” Source location Response from Department of Health and Social Care
Open published response
19 Sep 2025 Mr Luke John Chatterton · Prevention of Future Deaths report South London
View report summary
Concerns raised 4 Lack of a national formal guideline for management of bowel obstruction View source Delays in accessing advanced life support resuscitation for detained patients View source Failure of mental health hospitals to provide advanced life support resuscitation without acute hospital co-location View source Failure to identify the risks of deterioration and death from suspected acute obstruction in patients chronically on Clozapine View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Luke John Chatterton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Luke John Chatterton had a history of Clozapine-related constipation and developed vomiting, severe pain and suspected intestinal obstruction. He was discharged from the emergency department after an X-ray, later deteriorated and suffered a cardiac arrest, with delays in advanced life support before he died. The principal concerns were the safety and timeliness of resuscitation for detained mental health patients and the identification and escalation of risks associated with suspected obstruction in patients taking Clozapine.
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 national formal guideline for management of bowel obstruction
Wider context from the report “2. The acute Trust has taken a number of steps to facilitate identifying the risks of a patient who is referred with suspected obstruction. Outstanding is the development with the mental health Trust of an educational package and guidelines for managing suspected acute obstruction, including pseudo-obstruction (a complication of Clozapine) and recognizing the rare but potentially fatal risks of anti-psychotics. There is currently no national formal guideline on management of bowel obstruction. Given the rarity of antipsychotic induced acute obstruction, there seems to be merit in alerting national professional bodies to enable consideration to be given to the development of a guideline, which might identify the use of red flags to escalate and investigate those at most risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in accessing advanced life support resuscitation for detained patients
Wider context from the report “1. The delays in accessing advanced life support (ALS) resuscitation in the MH hospital were worse than expected in the community. London Ambulance Service target for Category 1 calls is 7 minutes and yet it took 37 minutes before the paramedics arrived. Despite concerns that resuscitation skills were better to maintain in a MH Trust, Adrenaline and IV lines were part of the system at the time. Initially no IV line could be found, then none could be inserted. 25 minutes of asystole elapsed before Adrenaline was administered. Evidence was heard that MH Trusts cannot safely provide advanced life support resuscitation unless they are co-located with an acute hospital site. The National Quality Standards in mental health in patient care requires calling 999 immediately and strongly recommends provision of IV-line insertion and drug administration and a team leader with ALS skills, but the Resuscitation Council has apparently approved the Trust policy. Thus, the safety of a patient detained by the State, who has a cardio-respiratory arrest, would seem to vary according to post code, some not being close to acute hospital standards, and might even be worse than in the community. Given that those who suffer psychosis have increased risks of premature death, including suicide and cardiovascular deaths, in part related to treatment, the State would seem to have a responsibility to mitigate these risks, when compulsorily detaining them. It raises the question as to whether patients with high risk should have the right to choose a site where there is co-location of acute services and whether units with high concentration of detained psychotics should and can be safely equipped to provide Advanced Life Support.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of mental health hospitals to provide advanced life support resuscitation without acute hospital co-location
Wider context from the report “1. The delays in accessing advanced life support (ALS) resuscitation in the MH hospital were worse than expected in the community. London Ambulance Service target for Category 1 calls is 7 minutes and yet it took 37 minutes before the paramedics arrived. Despite concerns that resuscitation skills were better to maintain in a MH Trust, Adrenaline and IV lines were part of the system at the time. Initially no IV line could be found, then none could be inserted. 25 minutes of asystole elapsed before Adrenaline was administered. Evidence was heard that MH Trusts cannot safely provide advanced life support resuscitation unless they are co-located with an acute hospital site. The National Quality Standards in mental health in patient care requires calling 999 immediately and strongly recommends provision of IV-line insertion and drug administration and a team leader with ALS skills, but the Resuscitation Council has apparently approved the Trust policy. Thus, the safety of a patient detained by the State, who has a cardio-respiratory arrest, would seem to vary according to post code, some not being close to acute hospital standards , and might even be worse than in the community. Given that those who suffer psychosis have increased risks of premature death, including suicide and cardiovascular deaths, in part related to treatment, the State would seem to have a responsibility to mitigate these risks, when compulsorily detaining them. It raises the question as to whether patients with high risk should have the right to choose a site where there is co-location of acute services and whether units with high concentration of detained psychotics should and can be safely equipped to provide Advanced Life Support.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to identify the risks of deterioration and death from suspected acute obstruction in patients chronically on Clozapine
Wider context from the report “2. The acute Trust has taken a number of steps to facilitate identifying the risks of a patient who is referred with suspected obstruction. Outstanding is the development with the mental health Trust of an educational package and guidelines for managing suspected acute obstruction , including pseudo-obstruction (a complication of Clozapine) and recognizing the rare but potentially fatal risks of anti-psychotics . There is currently no national formal guideline on management of bowel obstruction. Given the rarity of antipsychotic induced acute obstruction, there seems to be merit in alerting national professional bodies to enable consideration to be given to the development of a guideline, which might identify the use of red flags to escalate and investigate those at most risk.
” Open source report
Concerns raised 11 Lack of robust clinical governance and multidisciplinary team processes for community urology services View source Delays in assessment, diagnosis, treatment and transfer of postoperative sepsis View source Lack of robust assessment and guidelines for independent private-sector practising privileges View source Lack of appraisal and mandatory assessment of community urology clinicians View source Lack of multidisciplinary assessment and senior consultant oversight of community urology patients View source Lack of independent review of deaths for learning and practice change View source Failure of senior clinicians to retain responsibility for patients throughout private hospital care View source Lack of regular morbidity and mortality review of community urology complications View source Failure to assess whether patients are fit for operative procedures at the hospital View source Failure to fully inform patients of clinicians’ relevant experience View source Failure to integrate community urology services with hospital-based consultant-led urology services View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Keith James Hankin · 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
Keith James Hankin was admitted for an elective optical urethrotomy on 8 September 2023, developed sepsis shortly after the procedure, was transferred to Worthing Hospital, and died there on 11 September 2023. The report identifies concerns about poor clinical governance and lack of integration, oversight and clinician assessment within the Community Urology Service, as well as multiple omissions in his pre-operative, intra-operative and post-operative care at Goring Hall Hospital, including delays in recognising and treating sepsis and transferring him for further management.
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 robust clinical governance and multidisciplinary team processes for community urology services
Wider context from the report “1. Lack of clinical governance of the Community Urology Service (CUS) by the Integrated Care Board (ICB) who commissioned the service and Sussex Medical Chambers (SMC) who were responsible for providing the service
The Integrated Care Board contracted Sussex Medical Chambers to provide a Community Urology Service through any qualified provider in 2015 and renewed the contract through a competitive tendering process twice subsequently. The ICB used a generic contract supplied by NHS England to contract the service. Neither the IB nor SMC were able to provide any evidence of robust clinical governance or multi-disciplinary team processes to ensure best practice of urology services from inception to date.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in assessment, diagnosis, treatment and transfer of postoperative sepsis
Wider context from the report “6. Management of Mr Hankin at Goring Hall Hospital
There were multiple omissions in the pre-operative, intra-operative and post operative care provided by Goring Hall Hospital which individually and collectively contributed to Mr Hankin’s death. This included a failure to recognise Mr Hankin underlying medical co-morbidities rendered him unfit to have his operative procedure at the hospital. More specifically the post-operative assessment and support provided by the consultant anaesthetist and surgeon led to a delay in assessing and diagnosing sepsis and thereafter giving appropriate and timely antibiotics and facilitating an earlier transfer to the NHS Hospital for further management . This gives rise to a concern that there was a lack of understanding by the senior clinicians (in the absence of any local and national guidelines provided at the inquest) requiring them to remain responsible for the care of patients throughout their time in a private hospital rather than delegating the care to a Resident Medical Officer who is more likely than not to be insufficiently experienced in managing such critical 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 Lack of robust assessment and guidelines for independent private-sector practising privileges
Wider context from the report “4. Practicing Privileges within the private sector
████████ set up and led the CUS under the auspices of SMC. The ICB contractually required this service to be run by a consultant urologist. ████████ had not held a formal consultant urologist position within the NHS prior to tendering for this work. It remains unclear as to how ████████ was provided with practicing privileges at a private hospital as a consultant and was therefore able to practice independently and without scrutiny. This gives rise to a concern that there is a lack of robust assessment and guidelines, both locally and nationally, as to how clinicians are given practising privileges to work independently outside of the NHS to the potential detriment of patient care. It also gives rise to a concern that patients are not being fully informed of the relevant experience of such clinicians thereby breaching the statutory duty of candour responsibility of all hospitals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 appraisal and mandatory assessment of community urology clinicians
Wider context from the report “3. Lack of appraisal and mandatory assessment of clinicians employed by CUS
There was an absence of any appraisal and/or mandatory assessments within the CUS or the ICB and SMC for the associate specialist clinicians who were working extra-contractually outside of their NHS work. No evidence was provided as to their experience and competency. This gives rise to a concern that their working practices are insufficiently assessed and fails to fulfil GMC ‘good practice’ guidelines. Likewise, no evidence was provided regarding regular morbidity and mortality reviews of complications by the ICB, CUS and SMC such as when patients re-present to NHS hospitals with complications arising from the CUS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 multidisciplinary assessment and senior consultant oversight of community urology patients
Wider context from the report “2. Lack of Integration of the Community Urology service with NHS Hospital Urology Services
The CUS provided community-based urology services with non-consultant grade urologists without any oversight or integration with hospital-based consultant led urology services. Whilst there was an opportunity for CUS to refer more complex patients to NHS Hospital Trusts the ‘silo’ effect of these 2 services was such that they effectively worked independently of each other. The absence of a robust multidisciplinary team assessment within the CUS and the lack of senior clinical oversight of community urology patients by NHS consultant clinicians leads to a concern that the urology service is fragmented and does not effectively support urology patients within the region to confirm best practice and optimal treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of independent review of deaths for learning and practice change
Wider context from the report “5. Learning from Mr Hankin’s death
The ICB did not independently review the circumstances of Mr Hankin’s death to confirm if there was any learning or changes in practice to prevent further deaths. Likewise, SMC relied on ████████ to inform them and investigate Mr Hankin’s death without considering the inherent conflict of interest in so doing . The lack of an independent review prevented any proactive learning and changes in practice following the death of Mr Hankin. This gives rise to a concern that the system within the ICB and SMC are insufficiently robust and could – as it was with Mr Hankin – prevent transparency and openness as to the circumstances of his death and limit any learning and or necessary changes in practice to prevent 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 senior clinicians to retain responsibility for patients throughout private hospital care
Wider context from the report “6. Management of Mr Hankin at Goring Hall Hospital
There were multiple omissions in the pre-operative, intra-operative and post operative care provided by Goring Hall Hospital which individually and collectively contributed to Mr Hankin’s death. This included a failure to recognise Mr Hankin underlying medical co-morbidities rendered him unfit to have his operative procedure at the hospital. More specifically the post-operative assessment and support provided by the consultant anaesthetist and surgeon led to a delay in assessing and diagnosing sepsis and thereafter giving appropriate and timely antibiotics and facilitating an earlier transfer to the NHS Hospital for further management. This gives rise to a concern that there was a lack of understanding by the senior clinicians (in the absence of any local and national guidelines provided at the inquest) requiring them to remain responsible for the care of patients throughout their time in a private hospital rather than delegating the care to a Resident Medical Officer who is more likely than not to be insufficiently experienced in managing such critical 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 Lack of regular morbidity and mortality review of community urology complications
Wider context from the report “3. Lack of appraisal and mandatory assessment of clinicians employed by CUS
There was an absence of any appraisal and/or mandatory assessments within the CUS or the ICB and SMC for the associate specialist clinicians who were working extra-contractually outside of their NHS work. No evidence was provided as to their experience and competency. This gives rise to a concern that their working practices are insufficiently assessed and fails to fulfil GMC ‘good practice’ guidelines. Likewise, no evidence was provided regarding regular morbidity and mortality reviews of complications by the ICB, CUS and SMC such as when patients re-present to NHS hospitals with complications arising from the CUS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to assess whether patients are fit for operative procedures at the hospital
Wider context from the report “6. Management of Mr Hankin at Goring Hall Hospital
There were multiple omissions in the pre-operative, intra-operative and post operative care provided by Goring Hall Hospital which individually and collectively contributed to Mr Hankin’s death. This included a failure to recognise Mr Hankin underlying medical co-morbidities rendered him unfit to have his operative procedure at the hospital . More specifically the post-operative assessment and support provided by the consultant anaesthetist and surgeon led to a delay in assessing and diagnosing sepsis and thereafter giving appropriate and timely antibiotics and facilitating an earlier transfer to the NHS Hospital for further management. This gives rise to a concern that there was a lack of understanding by the senior clinicians (in the absence of any local and national guidelines provided at the inquest) requiring them to remain responsible for the care of patients throughout their time in a private hospital rather than delegating the care to a Resident Medical Officer who is more likely than not to be insufficiently experienced in managing such critical 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 fully inform patients of clinicians’ relevant experience
Wider context from the report “4. Practicing Privileges within the private sector
████████ set up and led the CUS under the auspices of SMC. The ICB contractually required this service to be run by a consultant urologist. ████████ had not held a formal consultant urologist position within the NHS prior to tendering for this work. It remains unclear as to how ████████ was provided with practicing privileges at a private hospital as a consultant and was therefore able to practice independently and without scrutiny. This gives rise to a concern that there is a lack of robust assessment and guidelines, both locally and nationally, as to how clinicians are given practising privileges to work independently outside of the NHS to the potential detriment of patient care. It also gives rise to a concern that patients are not being fully informed of the relevant experience of such clinicians thereby breaching the statutory duty of candour responsibility of all hospitals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to integrate community urology services with hospital-based consultant-led urology services
Wider context from the report “2. Lack of Integration of the Community Urology service with NHS Hospital Urology Services
The CUS provided community-based urology services with non-consultant grade urologists without any oversight or integration with hospital-based consultant led urology services . Whilst there was an opportunity for CUS to refer more complex patients to NHS Hospital Trusts the ‘silo’ effect of these 2 services was such that they effectively worked independently of each other . The absence of a robust multidisciplinary team assessment within the CUS and the lack of senior clinical oversight of community urology patients by NHS consultant clinicians leads to a concern that the urology service is fragmented and does not effectively support urology patients within the region to confirm best practice and optimal treatment.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete clear, patient-focused guidance explaining NHS and independent-sector care, private-hospital consultant arrangements, emergency provision, handovers and questions for providers.
Verbatim wording from the response “You also raised concerns about privileges to practice in private hospitals. In response to Recommendation 3 of the Paterson Inquiry report (published in 2020), this Department is currently completing clear, patient-focused information that explains the differences” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Integrated Care Boards are responsible for enforcing contracts and ensuring independent-sector providers meet patients’ needs.
Verbatim wording from the response “Those providers in receipt of NHS contracts must meet additional requirements, including meeting the provisions of the NHS Provider License and the NHS Standard Contract. These additional measures put in place specific standards which must be met. Contracts to private providers can be and are terminated where these are not met. ICBs are responsible for enforcing contracts with providers, including independent sector providers in their area, and are best placed to ensure providers are meeting the needs of their patients.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing governance processes, quality oversight and provider review were considered sufficient for the Community Urology Service.
Verbatim wording from the response “Regarding the commissioning of the CUS, Care Quality Commission (CQC) Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires effective governance processes are in place to complete registration of a regulated service, and the ICB have a contracting checklist that confirms provider governance is in place. As such, SMC have these processes in place, but this was unfortunately not shared at the inquest. Their current overall CQC rating is good.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing urology pathway, referral routes and service specification were considered sufficient to address concerns about siloing.
Verbatim wording from the response “With view to the siloing of CUS and NHS hospital urology work, the CUS is part of the Urology Pathway and manages “low risk” individuals. There are referral routes to the NHS pathway as clinically required. An issue was raised by the NHS Consultant giving evidence at the inquest for University Hospitals Sussex, but no formal concerns were raised to the ICB and this remains the case. The CUS service specification was met by the Provider, and all recruitment checks are managed by the Providers of the service.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The GMC is responsible for doctors’ registration and standards, while designated bodies oversee appraisals and related fitness-to-practise concerns.
Verbatim wording from the response “The General Medical Council (GMC) is responsible for ensuring that doctors have the necessary skills and knowledge to join its UK registers. All doctors must register with the GMC, and meet the expected standards set out in the GMC’s Good medical practice to work in the UK: https://www.gmc-uk.org/professional-standards/standards-for-doctors/good-medical-practice. Doctors must also hold a licence to practice medicine.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The provider’s serious-incident review and ICB scrutiny were considered sufficient; an independent review would be considered only if learning was inadequate.
Verbatim wording from the response “Regarding reviewing the causes of Mr Hankin’s death and the risk of a lack of transparency, Mr Hankin’s case was reviewed by the provider under the National Serious Incident (SI) framework as it occurred in 2023. NHS Sussex have reviewed the SI as per ICB scrutiny process and the SI has been closed. This provider review is the same process that any provider would undertake following the SI Framework. The ICB would consider an independent review if the quality of the provider report was an issue or did not elicit appropriate learning. The provider SI identified appropriate learning and subsequent actions.” Source location Response from Department for Health and Social Care
Open published response
3 Sep 2025 Margaret Bailey · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of ability and equipment for carers to carry out basic observations of unwell clients View source Lack of an algorithm for office call handlers to triage clients who appear unwell and determine a course of action 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
Margaret Bailey · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Margaret Bailey, who was bed-bound and wholly dependent on personal care, became unwell at home on 17 December 2023, later vomited while resting in bed, and was found unresponsive. The medical cause of death was aspiration of gastric contents following an episode of vomiting. Concerns included the absence of a triage algorithm for calls reporting that a client was unwell and the lack of equipment or ability to take basic observations, including a temperature reading.
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 ability and equipment for carers to carry out basic observations of unwell clients
Wider context from the report “2. There was no ability for the carer reporting that Margaret was unwell to carry out any basic observations, neither before the call to the office nor after it , in order that Margaret could be monitored as per the advice given or to at least provide a baseline for monitoring, not even a temperature reading . Most family homes, caring for children or physically vulnerable adults, would have at least a thermometer, and perhaps a pulse oximeter, maybe even a blood pressure machine.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 algorithm for office call handlers to triage clients who appear unwell and determine a course of action
Wider context from the report “1. On the ‘office’ receiving a call from a carer reporting, as here, that a client appears to be unwell there is no algorithm for the call handler (who tends to be an assistant manager/manager but with no medical background) to follow to triage the client, setting out why the client appears unwell and to then determine a course of action . The direction of the conversation is simply left to the ‘office’.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing CQC regulation and reasonable initial guidance are considered sufficient; further action is not considered likely to prevent a similar incident.
Verbatim wording from the response “The Care Quality Commission (CQC) requires all providers to have, at a minimum, baseline training and policies in place for staff to follow in the event a person in receipt of care experiences a deterioration in health or change in their condition or needs. This includes ensuring appropriate escalation channels are in place for staff to follow. Where a provider does use an algorithm to support the triage of phone calls, in instances such as these, CQC may review algorithms, alongside a provider’s general operating systems and day-to-day processes.” Source location Response from Department of Health and Social Care
Open published response
20 Aug 2025 Ricky O'Connell · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Insufficient ambulance service capacity to meet demand View source Delays in clearing ambulances from emergency departments within accepted turnaround times 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
Ricky O'Connell · 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
Ricky O'Connell's overnight symptoms deteriorated and his partner called an ambulance, but it had not arrived by the time he collapsed. He was treated by his family and ambulance staff, transported to hospital, and died there on 27 January 2025. The principal concerns were significant ambulance delays, including delays caused by prolonged hospital handovers, high demand, and limited vehicle availability, with evidence that an ambulance should have arrived before he collapsed.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient ambulance service capacity to meet demand
Wider context from the report “1. The inquest heard evidence that it was accepted that adherence to the timescales should have resulted in an ambulance arriving before he collapsed. The evidence given was that NWAS had done a huge amount of work to try to improve ambulance response times. This included improved staffing and call handling. However delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls including category 2 calls such as the one for Mr O’Connell.
2. The inquest was told that the ambulance service was generally operating at full stretch due to the demand for their services . The reasons for the demand were multi factorial and included challenges in accessing primary care.
3. The inquest was told that generally the period towards the end of a nightshift could be the busiest and resulted in waiting times increasing further . On the day in question across GM some hospitals were taking up to 60 minutes extra over the accepted turnaround time to clear ambulances. This led to significant challenges for NWAS.
4. The inquest was told that in Greater Manchester all of the Trusts have improved their turnaround times overall in the last few months but due to very significant delays in ambulance turnaround times at other Trusts in particular in Cheshire and Merseyside, NWAS were still being adversely impacted in terms of available vehicles to respond to calls across the North 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 Delays in clearing ambulances from emergency departments within accepted turnaround times
Wider context from the report “1. The inquest heard evidence that it was accepted that adherence to the timescales should have resulted in an ambulance arriving before he collapsed. The evidence given was that NWAS had done a huge amount of work to try to improve ambulance response times. This included improved staffing and call handling. However delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls including category 2 calls such as the one for Mr O’Connell.
2. The inquest was told that the ambulance service was generally operating at full stretch due to the demand for their services. The reasons for the demand were multi factorial and included challenges in accessing primary care.
3. The inquest was told that generally the period towards the end of a nightshift could be the busiest and resulted in waiting times increasing further. On the day in question across GM some hospitals were taking up to 60 minutes extra over the accepted turnaround time to clear ambulances . This led to significant challenges for NWAS.
4. The inquest was told that in Greater Manchester all of the Trusts have improved their turnaround times overall in the last few months but due to very significant delays in ambulance turnaround times at other Trusts in particular in Cheshire and Merseyside, NWAS were still being adversely impacted in terms of available vehicles to respond to calls across the North West.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monitoring performance and working with NWAS and NHS England to sustain urgent and emergency care improvements.
Verbatim wording from the response “Efforts to reduce ambulance handover delays are also progressing. NWAS reports significant local collaboration between Integrated Care Boards (ICBs), Acute Trusts, and NHSE regional teams. These efforts aim to ensure safe and timely patient handovers, freeing up crews to respond to emergencies in the community.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide nearly £450 million in capital investment for same-day emergency care, mental health crisis assessment centres and new ambulances.
Verbatim wording from the response “We also published our Urgent and Emergency Care Plan for 2025/26 in June which focuses on improvements to deliver better UEC performance both daily and during winter pressures. Key actions include:” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve hospital patient flow so 78% of A&E patients are seen within four hours and reduce 12-hour waits.
Verbatim wording from the response “We also published our Urgent and Emergency Care Plan for 2025/26 in June which focuses on improvements to deliver better UEC performance both daily and during winter pressures. Key actions include:” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reduce ambulance handovers to a maximum of 45 minutes and average Category 2 response times to 30 minutes.
Verbatim wording from the response “We also published our Urgent and Emergency Care Plan for 2025/26 in June which focuses on improvements to deliver better UEC performance both daily and during winter pressures. Key actions include:” Source location Response from Department for Health and Social Care
Open published response
19 Aug 2025 Gemma May Weeks · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Lack of understanding of the health consequences of chronic ketamine use outside professional circles View source Lack of understanding of ketamine risks among the age group most at risk of starting use View source Lack of public understanding of the dangers of acute and chronic ketamine 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
Gemma May Weeks · 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
Gemma May Weeks, a long-term ketamine user, was found deceased on 26 January 2025 after consuming high levels of ketamine and another substance; the combined effects caused her death. The report raises concerns that the acute and chronic risks of ketamine, including addiction and severe bladder damage, are not well understood by the public, potential first-time users, and groups at greatest risk of starting to use it.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the health consequences of chronic ketamine use outside professional circles
Wider context from the report “2. I have concerns with regard to the following:
i. The dangers and risk associated with both acute and chronic ketamine use are not well understood by the public and potential first time users of the drug. Ketamine’s classification as a class B controlled drug may give an impression that the dangers associated with its use are reduced as compared with class A drugs.
ii. There is little understanding of the risks and dangers of ketamine use amongst the age group that appear to be at most risk of starting to use the drug.
iii. The health consequences of chronic ketamine use are well understood by those that encounter them, including drug treatment providers and those working in healthcare. Those consequences are not, however, well understood outside of those circles.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 ketamine risks among the age group most at risk of starting use
Wider context from the report “2. I have concerns with regard to the following:
i. The dangers and risk associated with both acute and chronic ketamine use are not well understood by the public and potential first time users of the drug. Ketamine’s classification as a class B controlled drug may give an impression that the dangers associated with its use are reduced as compared with class A drugs.
ii. There is little understanding of the risks and dangers of ketamine use amongst the age group that appear to be at most risk of starting to use the drug.
iii. The health consequences of chronic ketamine use are well understood by those that encounter them, including drug treatment providers and those working in healthcare. Those consequences are not, however, well understood outside of those circles.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 public understanding of the dangers of acute and chronic ketamine use
Wider context from the report “2. I have concerns with regard to the following:
i. The dangers and risk associated with both acute and chronic ketamine use are not well understood by the public and potential first time users of the drug. Ketamine’s classification as a class B controlled drug may give an impression that the dangers associated with its use are reduced as compared with class A drugs.
ii. There is little understanding of the risks and dangers of ketamine use amongst the age group that appear to be at most risk of starting to use the drug.
iii. The health consequences of chronic ketamine use are well understood by those that encounter them, including drug treatment providers and those working in healthcare. Those consequences are not, however, well understood outside of those circles.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and issue joint advice with the National Police Chiefs’ Council to police and local authorities on festivals, drugs, and alcohol.
Verbatim wording from the response “Furthermore, DHSC and Home Office ministers wrote to festival organisers this summer, asking them to work closely with police and health partners on their harm reduction and first aid measures, which included highlighting the dangers of ketamine. The Department also worked with the National Police Chiefs’ Council on a joint letter and advice for the police and local authorities about festivals, drugs, and alcohol, to minimise the risk of harm to individuals at these events.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch a national mass- and social-media campaign on new drug-use patterns, sustained ketamine use, and associated bladder damage.
Verbatim wording from the response “The Department is working to increase awareness of the risks and associated health harms of sustained ketamine use. We are planning a national campaign to raise awareness on new patterns of drug use and their associated risk, with particular focus on sustained ketamine use and the damage it can cause to the bladder. The campaign, planned to launch in coming months, will utilise mass and social media, including a short film and social media influencers discussing the topic. The campaign will also disseminate information for a variety of stakeholders who come into contact with people at risk, such as teachers and local public health teams. This campaign complements the Government’s existing drug information and advice service called Talk to FRANK. This service aims to reduce drug misuse and its harms by increasing awareness, particularly for young people and parents.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Write to festival organisers requesting coordinated harm-reduction and first-aid measures that highlight ketamine dangers.
Verbatim wording from the response “Furthermore, DHSC and Home Office ministers wrote to festival organisers this summer, asking them to work closely with police and health partners on their harm reduction and first aid measures, which included highlighting the dangers of ketamine. The Department also worked with the National Police Chiefs’ Council on a joint letter and advice for the police and local authorities about festivals, drugs, and alcohol, to minimise the risk of harm to individuals at these events.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Home Office is responsible for responding to concerns about ketamine’s classification under the Misuse of Drugs Act 1971.
Verbatim wording from the response “I know that you sent your report to the Home Secretary and Department for Education (DfE) too. Home Office Ministers will be replying in relation to your concern about the classification of ketamine under the Misuse of Drugs Act 1971. My response will focus on concerns your report raised over the dangers and harms of ketamine use and that these dangers are little understood by both the firsttime users and younger age groups.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local authorities, Combating Drugs Partnerships and treatment providers lead prevention, harm-reduction and treatment interventions, including awareness raising.
Verbatim wording from the response “Alongside the work DHSC is conducting, widespread action is already in progress through local and regional initiatives. Local authorities, Combating Drugs Partnerships, and treatment providers lead on prevention, harm reduction, and treatment interventions, which includes awareness raising. Many of the national treatment providers, as well as local areas, have developed bespoke awareness-raising resources and approaches in response to ketamine, and a number have held events for professionals working in the field.” Source location Response from Department of Health and Social Care
Open published response
12 Aug 2025 Chloe Louise Barber · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 4 Insufficient knowledge among healthcare and social workers about provision of s117 Mental Health Act 1983 aftercare View source Lack of clear guidance on the location and personnel authorised to administer depot antipsychotic preparations View source Lack of a clearly defined transition pathway between CAMHS and adult psychiatric services View source Failure of healthcare and social workers to closely liaise with each other and allied professionals 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
Chloe Louise Barber · 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
Chloe Louise Barber, who had a history of self-harm and multiple overdoses and had been detained under the Mental Health Act, was found at home on 3 November 2021 and was confirmed dead at 17:05. The report identified concerns about transition pathways between CAMHS and adult psychiatric services, guidance on administering depot antipsychotic preparations, and understanding of section 117 aftercare responsibilities.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient knowledge among healthcare and social workers about provision of s117 Mental Health Act 1983 aftercare
Wider context from the report “3. There was considerable uncertainty and ignorance about the provision of aftercare pursuant to s117 of the Mental Health Act 1983 amongst some healthcare workers and social workers , who should in any event be closely liaising with each other as well as with other allied professionals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance on the location and personnel authorised to administer depot antipsychotic preparations
Wider context from the report “2. Concern was expressed by professional witnesses and experts that there are no clear guidelines about where and by whom depot preparations of antipsychotic may be administered .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 clearly defined transition pathway between CAMHS and adult psychiatric services
Wider context from the report “1. Evidence was heard at inquest from several expert witnesses that concern exists and continues to exist nationwide that there is not necessarily an clearly defined pathway that assists young persons making the transition between Childhood and Adolescent Mental Health Service (CAMHS) and adult psychiatric services , to ensure a smooth transit and continuity of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of healthcare and social workers to closely liaise with each other and allied professionals
Wider context from the report “3. There was considerable uncertainty and ignorance about the provision of aftercare pursuant to s117 of the Mental Health Act 1983 amongst some healthcare workers and social workers, who should in any event be closely liaising with each other as well as with other allied professionals .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish statutory guidance clarifying joint discharge planning and section 117 aftercare funding responsibilities.
Verbatim wording from the response “We are aware that there can sometimes be disagreements between organisations as to which one should be responsible for aftercare under section 117, which can delay access to aftercare. To address this, statutory guidance on discharges from mental health inpatient settings² was published in January 2024 which provides clarity in relation to how organisations across the health system work together to ensure effective discharge planning and the best outcomes for people who are discharged from hospital. It includes additional guidance on how budgets and responsibilities are shared to pay for aftercare under section 117. Integrated care boards, as commissioners of health services in their areas, should ensure that all providers of mental health services are aware of this guidance.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local authorities and integrated care boards are jointly responsible for arranging section 117 aftercare and ensuring providers know the relevant guidance.
Verbatim wording from the response “With regard to your concerns around a lack of knowledge amongst some healthcare staff and social workers about section 117 aftercare, it is vital that organisations across the health system work together to ensure effective discharge planning and the best outcomes for people who are discharged from hospital. Section 117 of the Mental Health Act places a joint duty on local authorities and integrated care boards, in co-operation with voluntary agencies, to provide or arrange for the provision of aftercare to patients detained in hospital for treatment under section 3 (and some other sections) who then cease to be detained.” Source location Response from Department for Health and Social Care
Open published response
8 Aug 2025 Jessica Lynda Smithson · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 6 Unavailability of arrangements for locating people at immediate risk across all charity crisis text services View source Failure of crisis text services to use Greater Manchester mental health pathways for early referral View source Failure to provide crisis text services across all ICBs View source Lack of standard policies and procedures for responding to immediate suicide risk View source Failure of charity crisis text services to link with local NHS Trusts and pathways View source Lack of a commissioned crisis text mental health support service in Greater Manchester View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jessica Lynda Smithson · 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
Jessica Lynda Smithson, aged 27, died by suicide after contacting a crisis text mental health service following an alleged serious sexual assault. The service did not contact the Metropolitan Police despite messages indicating an immediate risk to her life. The report identified concerns about inconsistent procedures among charity crisis text services and the absence of a commissioned crisis text mental health service in Greater Manchester.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of arrangements for locating people at immediate risk across all charity crisis text services
Wider context from the report “(b) At present this gap in a health-related service is being filled by charity organisations who have different policies and processes regarding actions to be taken if a person is at immediate risk of suicide. The charities are not under the Department of Health so there is no standard policy or procedure for them to follow if there is a real and immediate risk to a service user’s life.
Hence there is a lack of consistency as to the support an individual can receive when there is an immediate risk to their life, for example whilst the charity involved in this case have an agreement with the Metropolitan Police Service to help locate someone whose whereabouts are unknown, this is not the case for all charities .
In addition, as they are not linked into local NHS Trusts, they have limited ability to understand local mental health NHS pathways or to offer a more co-ordinated response where someone is already under local mental health services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 crisis text services to use Greater Manchester mental health pathways for early referral
Wider context from the report “2. Within the Greater Manchester Area there is no commissioned crisis text mental health support service. Whilst GM residents can message national services, often the location of an individual texter will not be known.
The court heard from Greater Manchester Police that they receive a significant number of referrals which have been sent by this crisis service to the Metropolitan Police, almost one a day where there has been a real and immediate risk to a person’s life identified. All of these referrals require an immediate police response (they are outside of Right Care Right Person). If there was a GM commissioned service, it is likely that any search for the location of the individual would be done by GMP and would shorten the timeframe in which they could respond to the risk.
In addition, a GM commissioned service would have a greater understanding of local pathways in order to refer people who may have a deteriorating mental health before they reached the point of crisis .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 crisis text services across all ICBs
Wider context from the report “(a) The NHSE indicated in their April 2024 Crisis Text Support Guidance and Specification document that they will oversee the rollout of these services which was expected to be rolled out by the end of March 2025. This has now been extended to March 2026.As of to date the evidence indicates only 10 have set up such a service with another 11 in the process of doing so . Some ICBs have indicated that they have no plans to do so .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 standard policies and procedures for responding to immediate suicide risk
Wider context from the report “(b) At present this gap in a health-related service is being filled by charity organisations who have different policies and processes regarding actions to be taken if a person is at immediate risk of suicide . The charities are not under the Department of Health so there is no standard policy or procedure for them to follow if there is a real and immediate risk to a service user’s life .
Hence there is a lack of consistency as to the support an individual can receive when there is an immediate risk to their life , for example whilst the charity involved in this case have an agreement with the Metropolitan Police Service to help locate someone whose whereabouts are unknown, this is not the case for all charities.
In addition, as they are not linked into local NHS Trusts, they have limited ability to understand local mental health NHS pathways or to offer a more co-ordinated response where someone is already under local mental health services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 charity crisis text services to link with local NHS Trusts and pathways
Wider context from the report “(b) At present this gap in a health-related service is being filled by charity organisations who have different policies and processes regarding actions to be taken if a person is at immediate risk of suicide. The charities are not under the Department of Health so there is no standard policy or procedure for them to follow if there is a real and immediate risk to a service user’s life.
Hence there is a lack of consistency as to the support an individual can receive when there is an immediate risk to their life, for example whilst the charity involved in this case have an agreement with the Metropolitan Police Service to help locate someone whose whereabouts are unknown, this is not the case for all charities.
In addition, as they are not linked into local NHS Trusts , they have limited ability to understand local mental health NHS pathways or to offer a more co-ordinated response where someone is already under local mental health services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 commissioned crisis text mental health support service in Greater Manchester
Wider context from the report “2. Within the Greater Manchester Area there is no commissioned crisis text mental health support service . Whilst GM residents can message national services, often the location of an individual texter will not be known .
The court heard from Greater Manchester Police that they receive a significant number of referrals which have been sent by this crisis service to the Metropolitan Police, almost one a day where there has been a real and immediate risk to a person’s life identified. All of these referrals require an immediate police response (they are outside of Right Care Right Person). If there was a GM commissioned service, it is likely that any search for the location of the individual would be done by GMP and would shorten the timeframe in which they could respond to the risk .
In addition, a GM commissioned service would have a greater understanding of local pathways in order to refer people who may have a deteriorating mental health before they reached the point of crisis.
” 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 Request regular progress reports on national integrated crisis text service delivery.
Verbatim wording from the response “As set out in the Suicide Prevention Strategy for England, mental health crisis text services are an important part of delivering accessible and effective mental health support across the country. NHS England has confirmed that all integrated care boards (ICB) have been asked to put in place integrated crisis text services and ICBs have now submitted their plans, with delivery expected across all areas by Spring 2026 and we have been requesting regular progress reports on this.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Independent charitable organisations providing crisis text services are outside Government and NHS control.
Verbatim wording from the response “I hope you will understand that charitable organisations providing crisis text services are independent of both Government and the NHS.” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Greater Manchester ICB is expected to address the lack of a locally commissioned crisis text support service.
Verbatim wording from the response “I would expect your concerns regarding the current lack of a locally commissioned crisis text support service to be addressed by NHS Greater Manchester ICB in its response to your report, and I understand from NHS England’s response to you that it will be reviewing the ICB’s response to consider whether any further actions are required.” Source location Response from Department for Health and Social Care
Open published response
6 Aug 2025 Jacob Matthew WOODERSON · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure to ensure patients retain advice about Elvanse adverse side effects View source Reliance on unreliable patient-provided heart rate and blood pressure observations in remote consultations View source Risk of serious cardiac side effects from Elvanse during dose escalation 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
Jacob Matthew WOODERSON · 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
Jacob Wooderson, who was being treated with Elvanse for ADHD, increased his dosage to 70 mg in August 2024 and subsequently experienced poor sleep and exhaustion before collapsing and dying at home on 23 August 2024. The inquest recorded sudden arrhythmic death syndrome, with Elvanse treatment for ADHD as a contributing factor, although the precise cause of the arrhythmia could not be established. Concerns included inadequate monitoring and documentation of heart rate, blood pressure and medication advice, particularly following dosage increases and during remote consultations.
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 patients retain advice about Elvanse adverse side effects
Wider context from the report “2) Symptoms of ADHD can include forgetfulness and problems with inattention. Consequently, there is a risk that patients may not recall verbal advice regarding the adverse side effects of Elvanse , particularly if it is only given at the outset of treatment or is not followed up in writing .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Reliance on unreliable patient-provided heart rate and blood pressure observations in remote consultations
Wider context from the report “3) The practice of remote consultations may mean that prescribers are reliant upon patients providing heart rate and blood pressure data outside of the consultation . Consequently, there is the potential for clinical decisions to be based on unreliable 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 Risk of serious cardiac side effects from Elvanse during dose escalation
Wider context from the report “1) Elvanse is an amphetamine-based medication which can have fatal cardiac side effects . It is increasingly being prescribed in the NHS and in the private sector for ADHD symptoms. As the dosage of Elvanse may increase gradually over a period of months, there is the potential for a patient that has previously tolerated the medication to develop adverse side effects . Monitoring of heart rate and blood pressure may help identify serious side effects at an early stage.
” 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 Prescribers, not the Department, decide whether medicines can be safely prescribed and must account for relevant national clinical guidance.
Verbatim wording from the response “Ultimately, decisions about what medicines to prescribe are made by the doctor or healthcare professional responsible for that part of the patient’s care, and prescribers are accountable for their prescribing decisions. Prescribers must always satisfy themselves that the medicines they consider appropriate for their patients can be safely prescribed and that they take account of appropriate national guidance on clinical effectiveness – as detailed for ADHD management and Elvanse specifically in the above paragraphs. Prescribers are supported by specialist professional bodies (e.g. Royal Colleges) and held to account professionally by professional regulators, such as the General Medical Council (GMC).” Source location Response from Department for Health and Social Care
Open published response
Concerns raised 1 Failure to provide sufficient designated clinical space for Emergency Department patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Maureen Brenda Batchelor · 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
Maureen Brenda Batchelor was admitted to hospital with diarrhoea and vomiting, was diagnosed with gastroenteritis and aspiration pneumonia, and died on 26 February 2025 from septicaemia caused by aspiration pneumonia. The report raised concerns that patients were being treated in the Emergency Department corridor, a non-clinical area, because of insufficient capacity, with this practice continuing and no evidence as to when it would end.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficient designated clinical space for Emergency Department patients
Wider context from the report “During the inquest I heard evidence from clinicians at University Hospitals Sussex NHS Foundation Trust that when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved to and treated in the corridor as there was no clinical area available to do so. The area is not designated as a clinical area.
I understand that at the time of Mrs Batchelor's attendance on 25 February there were 25 patients in the Emergency Department corridor, and this increased to 32 patients.
Clinicians from University Hospitals Sussex NHS Foundation Trust gave evidence as to the action that is being taken by the Trust currently to (1) reduce the number of patients who present to the Emergency Department who could be seen by other services in the community and (2) to create an improved patient flow through the Royal Sussex County Hospital. The evidence was however that, despite these actions, the corridor remains in use for patients currently as there is insufficient space within the department to care for patients. When asked there was no evidence as to when this practice would no longer be necessary.
I was also advised that the use of corridors to care for patients is not only an issue at the Royal Sussex County Hospital, Brighton but is used throughout the country when the capacities of Emergency Departments has been reached and there is nowhere to treat patients and the only other alternative would be to hold patients in ambulances outside of the hospital.
A Prevention of Future Deaths report in relation to the use of the corridor for patient care was made during an investigation into a death which occurred in December 2022 and the use of the corridor remains ongoing.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish data on the prevalence of corridor care to improve transparency and drive improvement.
Verbatim wording from the response “Regarding your concerns on corridor care, the provision of clinical care in corridors is unacceptable. We will publish data on the prevalence of corridor care for the first time to support transparency and drive improvement. NHS England has been working with trusts since 2024 to put in place new reporting arrangements. The data quality is currently being reviewed, and we expect to publish the information shortly.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for addressing the concerns and has already provided a response.
Verbatim wording from the response “In preparing this response, my officials have made enquiries with NHS England and I understand they have already responded to address your concerns.” Source location Response from Department for Health and Social Care
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations