11 Aug 2015 Julia Ann Clarke Hayward · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Failure to document care plans for family members undertaking care obligations 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
Julia Ann Clarke Hayward · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Julia Ann Clarke Hayward died on 23 May 2014 after intentionally placing herself in the path of an oncoming train while suffering from mental illness. The inquest identified concern that care plans agreed when discharging mental health patients into the care of family members were not documented or provided to those family members, leading to uncertainty about their obligations.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to document care plans for family members undertaking care obligations
Wider context from the report “During the course of the inquest the evidence revealed that when a decision was made to discharge a patient home and into the care of a family member, following a mental health assessment. The Care Plan was agreed orally and not documented for the family member. Consequently, issues arose as to what was expected/anticipated of the family member under the Care Plan and what was understood by that family member as being their obligations.
” Open source report
7 Aug 2015 James Reuben Maxwell Adams · Prevention of Future Deaths report Cornwall
View report summary
Concerns raised 2 Lack of acute psychiatric beds in Cornwall View source Failure to staff designated mental health places of safety to the appropriate level View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Reuben Maxwell Adams · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Adams was found dead at home on 10 August 2012 with a plastic bag and helium cylinders, and suicide notes were found nearby. He had persistent depressive disorder, alcohol dependency and a mixed type personality disorder, and was being treated by mental health services. Concerns included the police response to a welfare concern, information sharing, shortages of acute psychiatric beds, and inadequate staffing at designated mental health places of safety.
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 acute psychiatric beds in Cornwall
Wider context from the report “The inquest heard how lessons had been learnt from the inquest and that the working relationship with the Devon and Cornwall Police and the local Mental Health Services (provided by Cornwall Partnership NHS Foundation Trust) had been improved and formalised through appropriate protocols and Memorandum of Understanding. One continuing difficulty was the “lack of acute psychiatric beds” in Cornwall. In addition, the police had found that on a regular basis, the designated mental health places of safety were not staffed to the appropriate level and the patient could not be left there. The result of this was that patients were being inappropriately detained in police cells by way of a safety net or were regularly being transported out of County as far as Manchester and Bournemouth to access the appropriate acute mental health bed.
Cornwall Partnership NH Foundation Trust representative advised the Coroner that Cornwall has pro-rata less acute mental health beds than the national average. The preferred option for the mental health professionals was to treat local patients locally where they are known or are able to build up relationships with the local mental health team which is something that cannot happen if the patient is transported out of County. Further, the treating Psychiatrist is required to travel to the out of county unit to review the patient which results in valuable Consultant time not being available to local patients which may need access to them at a critical time. The result of this is that unnecessary stress is put on patients which can result in a deterioration of the patients mental health (and possibility death) at a time when the patient needs increased support and treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to staff designated mental health places of safety to the appropriate level
Wider context from the report “The inquest heard how lessons had been learnt from the inquest and that the working relationship with the Devon and Cornwall Police and the local Mental Health Services (provided by Cornwall Partnership NHS Foundation Trust) had been improved and formalised through appropriate protocols and Memorandum of Understanding. One continuing difficulty was the “lack of acute psychiatric beds” in Cornwall. In addition, the police had found that on a regular basis, the designated mental health places of safety were not staffed to the appropriate level and the patient could not be left there . The result of this was that patients were being inappropriately detained in police cells by way of a safety net or were regularly being transported out of County as far as Manchester and Bournemouth to access the appropriate acute mental health bed.
Cornwall Partnership NH Foundation Trust representative advised the Coroner that Cornwall has pro-rata less acute mental health beds than the national average. The preferred option for the mental health professionals was to treat local patients locally where they are known or are able to build up relationships with the local mental health team which is something that cannot happen if the patient is transported out of County. Further, the treating Psychiatrist is required to travel to the out of county unit to review the patient which results in valuable Consultant time not being available to local patients which may need access to them at a critical time. The result of this is that unnecessary stress is put on patients which can result in a deterioration of the patients mental health (and possibility death) at a time when the patient needs increased support and treatment.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for commissioning acute mental health inpatient services in Cornwall rests with NHS Kernow Clinical Commissioning Group.
Verbatim wording from the response “Your main concern in this case was the lack of acute psychiatric beds in Cornwall and how this could continue to have an adverse impact on the care of mental health patients in this area. Commissioning mental health inpatient services is the responsibility of the local Clinical Commissioning Group (CCG) - in this case the NHS Kernow CCG. It commissions services for Cornwall from the Cornwall Partnership NHS Foundation Trust.” Source location James-Adams-Response
Open published response
6 Aug 2015 Robert Gordon John Hogg · Prevention of Future Deaths report Buckinghamshire
View report summary
Concerns raised 1 Failure of NHS Pathways toddler/child pathways to identify very sick children View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Robert Gordon John Hogg · 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
Robert Gordon John Hogg was taken to hospital with cold and temperature symptoms and was assessed and sent home. He later became lethargic and unresponsive in the urgent care centre waiting room, and his death was confirmed on 21 April 2014. An investigation identified concern that NHS Pathways toddler/child pathways were not necessarily identifying very sick children, and this was described as a continuing risk at the inquest.
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 NHS Pathways toddler/child pathways to identify very sick children
Wider context from the report “(2) The third area of concern stated specifically “NHS Pathways toddler/child Pathways are not necessarily highlighting/picking up very sick children . This is not the first event relating to incidents involving toddlers/children and this has been highlighted through our own Pathways Lead to NHS Pathways for investigation”
(3) The evidence given by ████████ during the Inquest was that no changes have been made to the toddler/child pathways , and that the third area of concern identified in the Investigation Report is a continuing risk .
” 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 the NHS Pathways system rests with HSCIC, which has provided the relevant response.
Verbatim wording from the response “The Health and Social Care Information Centre (HSCIC) is the national provider of information, data and IT systems for commissioners, analysts and clinicians in health and social care. HSCIC is an executive non-departmental public body and is responsible for the NHS Pathways system. NHS Pathways has provided a response which I am enclosing.” Source location 2015-0313-Response-by-Department-of-Health
Open published response
Concerns raised 1 Inadequate guidance for the general management of long-term tracheostomy patients with complex medical needs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anthony Dwyer · 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
Anthony Dwyer, a vulnerable long-term tracheostomy patient with complex medical needs, collapsed in hospital after removing his tracheostomy tube and suffered a hypoxic cardiac arrest. The substantive concern was the adequacy of guidance to the trust on the general management of long-term tracheostomy patients with complex medical needs.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate guidance for the general management of long-term tracheostomy patients with complex medical needs
Wider context from the report “The adequacy of guidance provided to trust in the general management long term tracheostomy patients with complex medical needs.
” 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 guidance on long-term tracheostomy patients with complex medical needs rests with NHS England’s patient safety team.
Verbatim wording from the response “Guidance in this area is the responsibility of the patient safety team at NHS England. The advice I have received is that adequate guidance is already available for staff caring for patients with a tracheostomy.” Source location 2015-0249-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing guidance is considered adequate for staff caring for patients with a tracheostomy.
Verbatim wording from the response “Guidance in this area is the responsibility of the patient safety team at NHS England. The advice I have received is that adequate guidance is already available for staff caring for patients with a tracheostomy.” Source location 2015-0249-Response-by-Department-of-Health
Open published response
23 Jul 2015 Doreen England · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 7 Lack of staff knowledge about pressure sore formation and prevention View source Lack of clear ward leadership View source Inadequate on-site medical cover View source Failure to provide staff training on pressure sore formation and prevention View source Failure to prepare care plans for patients at high risk of pressure sore formation View source Inadequate RMN training on pressure sores View source Failure to act on identified clinical risks View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Doreen England · 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
Doreen England, an 81-year-old woman with vascular dementia, developed a severe pressure sore during her admission to Rosemary Suite from 20 July 2014 and died on 30 September 2014. The principal concerns were the failure to prepare and implement a care plan despite her high risk, inadequate staff knowledge and training about pressure sore prevention, and insufficient ward leadership and medical cover.
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 staff knowledge about pressure sore formation and prevention
Wider context from the report “(1) Despite a waterlow score on admission confirming she was at high risk of pressure sore formation no care plan was prepared. Staff at the inquest confirmed they had a lack of knowledge about pressure sore formation and how to prevent pressure sores occurring. Staff working on mental health wards dealing with elderly patients must have a clear understanding of basic medical care in particular how pressure sores occur and what steps are required to address those at high risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clear ward leadership
Wider context from the report “(3) Rosemary suite had no leadership at the time. Staff were completing paperwork but not then actioning risks that were identified. The consultant and ward doctor were on leave at the same time and medical cover was only available from doctors off site who had to be requested to attend. The ward and trust need to ensure there is clear leadership on the ward with adequate medical cover.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate on-site medical cover
Wider context from the report “(3) Rosemary suite had no leadership at the time. Staff were completing paperwork but not then actioning risks that were identified. The consultant and ward doctor were on leave at the same time and medical cover was only available from doctors off site who had to be requested to attend. The ward and trust need to ensure there is clear leadership on the ward with adequate medical cover.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide staff training on pressure sore formation and prevention
Wider context from the report “(2) Since these events staff confirmed at the inquest that they had still not had training on pressure sore formation and prevention.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 prepare care plans for patients at high risk of pressure sore formation
Wider context from the report “(1) Despite a waterlow score on admission confirming she was at high risk of pressure sore formation no care plan was prepared. Staff at the inquest confirmed they had a lack of knowledge about pressure sore formation and how to prevent pressure sores occurring. Staff working on mental health wards dealing with elderly patients must have a clear understanding of basic medical care in particular how pressure sores occur and what steps are required to address those at high risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate RMN training on pressure sores
Wider context from the report “(4) Registered Mental Health Nurses at the inquest confirmed their RMN training had not covered the subject of pressure sores in any detail and they felt they had inadequate awareness and knowledge . This is a subject that should be covered in the RMN curriculum.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 act on identified clinical risks
Wider context from the report “(3) Rosemary suite had no leadership at the time. Staff were completing paperwork but not then actioning risks that were identified. The consultant and ward doctor were on leave at the same time and medical cover was only available from doctors off site who had to be requested to attend. The ward and trust need to ensure there is clear leadership on the ward with adequate medical cover.
” Open source report
Concerns raised 3 Lack of auditing and follow-up procedures for vaccination advice systems View source Failure of local healthcare provider systems to capture responsibility for advising all pregnant women about the importance of whooping cough vaccination View source Failure to maintain effective communication links between ante-natal healthcare providers 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
Isabella Rosa Drew · 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
Isabella Rosa Drew was a 29-day-old infant who contracted whooping cough in early September 2014 and died on 9 September 2014; the recorded causes of death were severe acute pneumonia and Bordetella pertussis. The report raised concerns that pregnant women were not consistently offered whooping cough vaccination, and that national guidance did not provide sufficient detail on local procedures, auditing, follow-up, and communication between antenatal healthcare providers.
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 auditing and follow-up procedures for vaccination advice systems
Wider context from the report “(1) consideration needs to be given as to whether there needs to be further and more explicit guidance as to how local healthcare providers ensure systems put in place effectively capture their responsibility to advise all pregnant women of the importance of whooping cough vaccination with provision for auditing and follow up procedures .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 local healthcare provider systems to capture responsibility for advising all pregnant women about the importance of whooping cough vaccination
Wider context from the report “(1) consideration needs to be given as to whether there needs to be further and more explicit guidance as to how local healthcare providers ensure systems put in place effectively capture their responsibility to advise all pregnant women of the importance of whooping cough vaccination with provision for auditing and follow up procedures.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain effective communication links between ante-natal healthcare providers
Wider context from the report “(2) a need for further national guidance regarding the importance of effective communication links between the various limbs of ante-natal healthcare providers .
” Open source report
16 Jul 2015 Stanley Oliver · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1 Lack of out-of-hours availability of GI Radiologists to perform percutaneous cholecystostomy View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stanley Oliver · 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
Stanley Oliver, aged 85, died at Salford Royal Hospital after being admitted with abdominal pain and a perforated gall bladder. A drainage procedure was not performed over the weekend because there was no out-of-hours rota for GI Radiologists, and the report raised concerns about the availability, communication arrangements and training needed for urgent procedures of this kind.
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 out-of-hours availability of GI Radiologists to perform percutaneous cholecystostomy
Wider context from the report “1. During the Inquest evidence was heard that:
i. There was no on call rota for a GI Radiologist to perform a percutaneous cholecystostomy out of hours and particularly over a weekend. The Hospital Trust indicated that a risk had been identified in relation to the unavailability of GI Radiologists out of hours and the Hospital that managed the risk by allowing the GI Radiologist to be contacted out of hours but the Trust accepted that there was no provision for the Radiologist to be available out of hours.
ii. The Consultant Surgeon gave evidence at the Inquest that availability of a GI Radiologist to perform a percutaneous cholecystostomy was critical to the management of a patient and he raised concerns that there would be a risk to life if a percutaneous cholecystostomy could not be performed out of hours, either overnight or over a weekend.
iii. I accepted evidence at the Inquest that the Salford Royal NHS Foundation Trust were considering actions to make GI Radiologist available out of hours and to establish a system for any Radiologist to contact a GI Radiologist our of hours for procedures to be conducted out of hours. However there was no confirmation that an out of hours on call rota was being considered for GI Radiologists either within the Salford Royal NHS Foundation Trust or for a rota relate to a wider area covering several other hospitals on the basis that an available Radiologist could travel to different hospitals to carry out a necessary procedure out of hours.
iv. Evidence was given at the Inquest that the unavailability of GI Radiologists was not limited to Salford but was a national problem in that there were very few out of hours on call rotas for GI Radiologists in hospitals in the United Kingdom.
It was accepted that a perforated gall bladder was a recognised condition, which occurred on a regular basis as an emergency presentation to hospital. In some cases surgical intervention would not be appropriate and an alternative treatment plan would involve the insertion of a percutaneous cholecystostomy drain or a drain to be inserted outside the gall bladder, both of which would require insertion by a GI Radiologist.
v. The evidence raised concerns that there is a risk of future deaths will occur unless action is taken to review the above issues.
” 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 Each local NHS Trust is responsible for providing out-of-hours rotas, availability procedures and staff training in those protocols.
Verbatim wording from the response “I note that your letter has been sent to the SRH Trust and I would expect the Trust to fully address these concerns.” Source location 2015-0281-Response-by-Department-of-Health
Open published response
14 Jul 2015 Emma Carpenter · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Lack of inpatient beds for mentally ill children and adolescents View source Lack of sustainable long-term commissioning for specialist eating disorder services for children and adolescents View source Lack of clear connections between mental health professionals and education pastoral care staff View source Failure of school nurses to attend multidisciplinary meetings reliably View source Lack of professional links between the specialist Eating Disorder Service and Bassetlaw Hospital 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
Emma Carpenter · 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
Emma Carpenter was treated as an outpatient by child and adolescent mental health services from February 2004 to November 2006 and died from multi-organ failure caused by severe anorexia nervosa. The report identified insufficient physical-health monitoring, lack of specialist paediatric or physician input, and delay in accessing effective inpatient treatment as concerns.
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 inpatient beds for mentally ill children and adolescents
Wider context from the report “2. There remains still a national lack of provision of inpatient beds for mentally ill children and adolescents including those who suffer from eating disorders .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 sustainable long-term commissioning for specialist eating disorder services for children and adolescents
Wider context from the report “1. Although the Trust has now set up a specialist Eating Disorder Service for children and adolescents, there is only short term funding in place for this service and a lack of commitment from Commissioners for its long term future .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 connections between mental health professionals and education pastoral care staff
Wider context from the report “4. In the absence of school nurses, there is a lack of clear connections between the mental health professionals and those in the education system who have responsibility for the pastoral care of mentally ill children and adolescents .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 school nurses to attend multidisciplinary meetings reliably
Wider context from the report “3. Although the view of mental health professionals was that it was important for school nurses to attend Multi Disciplinary Meetings to understand and assist with care planning, this does not happen on a regular, reliable basis due to lack of funding for school nurses.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of professional links between the specialist Eating Disorder Service and Bassetlaw Hospital
Wider context from the report “1. The Trust has now set up a specialist Eating Disorder Service for children and adolescents, and reports that although this service now has good professional links with named paediatricians at Kings Mill Hospital and Queen’s Medical Centre, there are no equivalent links with Bassetlaw Hospital .
” Open source report
10 Jul 2015 Colin Moulton · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Failure to provide the receiving triage nurse with access to and sight of the paramedic pro-forma View source Failure to notify the hospital trust of ambulance presence within hospital grounds View source Failure to document the receiving triage nurse's access to and sight of the paramedic pro-forma View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Colin Moulton · 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
Colin Moulton was discovered deceased on 14 February 2013 near the perimeter wall of the Irwell Unit at Fairfield General Hospital, after leaving the Accident and Emergency Department the previous day. Concerns included ineffective communication during handover, incorrect triage, failure to recognise confusion, and the absence of a formal capacity assessment or other documented measures when he attempted to leave. The inquest narrative stated that his death was contributed to by neglect.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the receiving triage nurse with access to and sight of the paramedic pro-forma
Wider context from the report “1. When Mr Moulton was admitted to A & E on the 13th February 2013, critical information was conveyed by means of an audible handover from the paramedic to the receiving triage nurse . Following this incident, the Pennine Acute Trust now requires the receiving triage nurse to have access to and have sight of the paramedic pro-forma with the additional requirement that those actions be documented. It would be helpful if an additional copy of the paramedic pro-forma could be given to and remain with the receiving triage nurse.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 notify the hospital trust of ambulance presence within hospital grounds
Wider context from the report “2. At approximately 5pm on the 13th February 2013, a number of administrative staff, whilst en-route home saw Colin Moulton within the hospital grounds near to the Irwell Unit. They perceived him to be ‘ in difficulty’. One of the staff members called for the assistance of an ambulance which duly attended and a paramedics on board apparently were unable to locate Mr Moulton. Had the Ambulance Trust notified the Hospital Trust of their presence within the hospital grounds, this may have tied in with earlier concerns in relation to Mr Moulton of which the Hospital Trust was aware. The Ambulance Trust is requested to consider whether in the future, third parties such as Hospital Trusts might be notified in such circumstances.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to document the receiving triage nurse's access to and sight of the paramedic pro-forma
Wider context from the report “1. When Mr Moulton was admitted to A & E on the 13th February 2013, critical information was conveyed by means of an audible handover from the paramedic to the receiving triage nurse. Following this incident, the Pennine Acute Trust now requires the receiving triage nurse to have access to and have sight of the paramedic pro-forma with the additional requirement that those actions be documented . It would be helpful if an additional copy of the paramedic pro-forma could be given to and remain with the receiving triage nurse.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department considers the concerns matters for local comment and resolution rather than national action.
Verbatim wording from the response “I consider that both of your concerns are for local comment and resolution and I note that you have sent a copy of your report to the NWAS. I am aware that NWAS has already responded, addressing the issues you raise and asking that you redirect your specific concerns to FGH for its consideration also.” Source location 2015-0267-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specific concerns should be redirected to Fairfield General Hospital for consideration after North West Ambulance Service’s response.
Verbatim wording from the response “I consider that both of your concerns are for local comment and resolution and I note that you have sent a copy of your report to the NWAS. I am aware that NWAS has already responded, addressing the issues you raise and asking that you redirect your specific concerns to FGH for its consideration also.” Source location 2015-0267-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing handover procedures should ensure triage staff access important patient information, so retaining paramedic notes is not required.
Verbatim wording from the response “NWAS has advised that its staff always leave a patient report form (PRF) at every hospital following a patient transfer. A copy of this form also remains with the patient following admission.” Source location 2015-0267-Response-by-Department-of-Health
Open published response
10 Jul 2015 Dorothy McDermott · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Lack of care staff training in the examination and care of pressure sores View source Failure to ensure suitable placements guaranteeing a place of safety for vulnerable individuals 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
Dorothy McDermott · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Dorothy McDermott, who was 80 and had been housebound for 2½ years, fell three times at home and was placed in emergency respite care. The care home provided residential but not nursing care, and staff were not trained to examine or care for pressure sores. An inquest concluded that opportunities to examine her sacrum were missed, and she died in hospital after developing a Grade 4 pressure sore and septicaemia.
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 care staff training in the examination and care of pressure sores
Wider context from the report “Dorothy McDermott was 80 years old. She had been housebound for 2½ years. She had been diagnosed with a urinary tract infection and was confused. On the 17th January 2015, she had fallen three times whilst at home. Paramedics advised a rapid response but they finished at 5.30pm. Mrs McDermott required a place of safety. Following discussions between the Local Authority’s emergency duty team and the out of hours service for the district nursing team, emergency respite care was arranged at the Littleborough Care Home to which Mrs McDermott was conveyed during the early hours of the 18th January. It was envisaged that Mrs McDermott would be reassessed on the 19th January. The Littleborough Care Home offered residential but not nursing care. Care staff at the home were not trained in either the examination for or care of pressure sores. That placement was inappropriate. The rationale for that decision one of availability with the facility of a ground floor bedroom which had been newly decorated.
Whilst appreciating that the decision to procure respite care was made ‘out of hours’ the overriding concern given the extent of Mrs McDermott’s vulnerability should have been to obtain a suitable placement which guaranteed a place of safety. Whilst not wishing to be prescriptive, formal Guidance is required to as to ensure that vulnerable individuals are appropriately placed by the Agencies involved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure suitable placements guaranteeing a place of safety for vulnerable individuals
Wider context from the report “Dorothy McDermott was 80 years old. She had been housebound for 2½ years. She had been diagnosed with a urinary tract infection and was confused. On the 17th January 2015, she had fallen three times whilst at home. Paramedics advised a rapid response but they finished at 5.30pm. Mrs McDermott required a place of safety. Following discussions between the Local Authority’s emergency duty team and the out of hours service for the district nursing team, emergency respite care was arranged at the Littleborough Care Home to which Mrs McDermott was conveyed during the early hours of the 18th January. It was envisaged that Mrs McDermott would be reassessed on the 19th January. The Littleborough Care Home offered residential but not nursing care. Care staff at the home were not trained in either the examination for or care of pressure sores. That placement was inappropriate. The rationale for that decision one of availability with the facility of a ground floor bedroom which had been newly decorated.
Whilst appreciating that the decision to procure respite care was made ‘out of hours’ the overriding concern given the extent of Mrs McDermott’s vulnerability should have been to obtain a suitable placement which guaranteed a place of safety. Whilst not wishing to be prescriptive, formal Guidance is required to as to ensure that vulnerable individuals are appropriately placed by the Agencies involved.
” Open source report
Concerns raised 2 Failure to assess home circumstances and available observation when discharging patients following head injury View source Failure to document discharge risk-factor assessments in clinical records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Toni Piel · 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
Toni Piel suffered a head injury in a fall at home on 10 December 2014 and was treated at hospital before being discharged. He was found dead at home on 23 December 2014, with the inquest concluding that he died from a head injury caused by a fall, although it was not established whether this was linked to the earlier injury. Concerns included that his home circumstances and the absence of anyone able to observe him were apparently not considered at discharge, and that risk factors were not documented.
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 assess home circumstances and available observation when discharging patients following head injury
Wider context from the report “i) At the time the deceased was discharged home following the head injury on 10 December 2014 the deceased’s home circumstances were apparently not taken into account . Had such an assessment been made it would have been noted that there was no-one able to observe the deceased at home . The NICE clinical guideline 175 issued January 2014 recommends that this should be taken into account.
ii) No assessment of the risk factors in discharging the deceased was documented in the deceased’s records.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to document discharge risk-factor assessments in clinical records
Wider context from the report “i) At the time the deceased was discharged home following the head injury on 10 December 2014 the deceased’s home circumstances were apparently not taken into account. Had such an assessment been made it would have been noted that there was no-one able to observe the deceased at home. The NICE clinical guideline 175 issued January 2014 recommends that this should be taken into account.
ii) No assessment of the risk factors in discharging the deceased was documented in the deceased’s records.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operational improvements to head injury assessment and discharge are the responsibility of the involved NHS trust.
Verbatim wording from the response “These are both operational matters for the trust involved. I note that your report has been sent to the Pennine Acute Hospitals NHS Trust. I understand that Pennine Acute has undertaken a review of this case which has resulted in actions to improve the management, supervision, assessment and discharge of head injury patients in their care. The Trust will provide you with full details in its response.” Source location 2015-0263-Response-by-Department-of-Health
Open published response
Concerns raised 1 Lack of regulation or licensing of e-cigarette fluid sales 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
Arti Hasmukh Lakhani · 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
Arti Hasmukh Lakhani became unwell after drinking one bottle of e-cigarette fluid at home, was taken to hospital on 11 January 2015, and died on 13 January 2015 despite attempts to save her. The principal concern was that the sale of e-cigarette fluid was not regulated or licensed.
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 regulation or licensing of e-cigarette fluid sales
Wider context from the report “That the sale of e-cigarette fluid is not regulated or licenced
” Open source report
1 Jun 2015 David Glyn Price · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to maintain an effective swab counting control during surgical procedures View source Failure to maintain complete, dated, signed and attributable handwritten medical and nursing notes View source Failure to review or discontinue repeat prescriptions when medicines are no longer needed or when required monitoring is missed View source Failure to recognise and act on clinically significant radiology findings 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
David Glyn Price · 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
David Glyn Price suffered a heart attack in early June 2011 and underwent surgery at Wythenshawe Hospital, during which a swab was inadvertently left inside his body attached to his heart; this gradually formed an abscess. Concerns included continued warfarin prescribing despite missed anticoagulation appointments, poor handwritten clinical records, failure to act on imaging showing a foreign body, and inadequate swab-count procedures.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an effective swab counting control during surgical procedures
Wider context from the report “4. There did not seem to be in place any, or any satisfactory, swab count policy , such that none of the nurses during any of the three heart procedures, noticed that there was a discrepancy .(UHSM)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain complete, dated, signed and attributable handwritten medical and nursing notes
Wider context from the report “2. The quality of the handwritten notes (both medical and nursing) was nothing short of very poor . They were frequently undated, unsigned and there was no indication in block letters as to who was completing the notes, his/her professional status etc.(For UHSM)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to review or discontinue repeat prescriptions when medicines are no longer needed or when required monitoring is missed
Wider context from the report “1.Before he was admitted to hospital his G.P. was prescribing warfarin and this continued over many months despite the fact that he failed on three occasions to attend the anti- coagulation clinic . There is apparently no system to prevent this happening . I have noted in many inquests that people who have “repeat prescriptions” continue to get all the drugs prescribed even if they are no longer needed or wanted , thus potentially placing the patient at considerable health risk but also costing the NHS a vast amount of money for unwanted and unused drugs.(For the Secretary of State)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and act on clinically significant radiology findings
Wider context from the report “3. Even though a “specialist radiologist” looked at the X-Rays, and noted that they appeared to show a foreign body within the thorax of the patient, this was not read or seen by any of the treating doctors , or if it was seen it was not in any way acted upon . (This was of course an image of the rogue swab which was left in the body.) (UHSM)
” Open source report
29 May 2015 Elizabeth Anne Lester · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Omission of chest-pain questions from the breathing-difficulties dispatch card View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elizabeth Anne Lester · 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
Elizabeth Anne Lester underwent a total knee replacement and was subsequently readmitted to hospital as an emergency. The report raises concern that the ambulance service’s scripted breathing-difficulties assessment did not ask about chest pain, resulting in a green response on the first call; chest pain was identified during a second call, when the response was escalated to red.
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 Omission of chest-pain questions from the breathing-difficulties dispatch card
Wider context from the report “As per National practice, the North West Ambulance Service uses Advanced Medical Dispatch System to prioritise calls, based on the answers to scripted questions. During the first call the call-handler asked the relevant questions and followed the “breathing difficulties” card. This card does not include any question as to whether the patient is suffering any chest pains. The call was allocated a green response and the “high volume script” was also given. In fact the patient was short of breath AND did have chest pains, but this was never enquired about.
On the second call to the Ambulance service, this aspect was asked about and the call was escalated to a Red response.
It is my firm belief, having come across this same issue in a number of inquests , that there is an omission in the ‘card’ for ALL breathing difficulties and it MUST be amended to include a question about chest pain. Breathing difficulties are frequently as a result of compromised heart and/or lung function and this should be queried.
I am told that the local ambulance service cannot alter the wording used but that this must be done by the suppliers of the software.
” 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 AMPDS users must ask Priority Dispatch directly to review and change the system’s call-handling questions.
Verbatim wording from the response “Users of AMPDS must contact Priority Dispatch directly if they feel that an element of the system needs to be reviewed and changed. I understand NWAS has responded to your report suggesting that you write directly to the AMPDS contact at Priority Dispatch UK asking for the changes that you have recommended to be considered. I would support this.” Source location 2015-0204-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department cannot provide further help implementing the proposed AMPDS call-handling changes.
Verbatim wording from the response “I am sorry that the Department cannot be of any further help in implementing the changes you suggest. However, I hope that you find this reply helpful and I am grateful to you for bringing the circumstances of Ms Lester’s death to my attention.” Source location 2015-0204-Response-by-Department-of-Health
Open published response
Concerns raised 6 Delays in ambulance crew handover at hospitals reducing ambulance availability View source Failure of the Pathways system to prompt CPR advice for patients with agonal breathing View source Failure by call handlers to give timely CPR advice View source Delays in ambulance arrival beyond the target response time View source Failure by ambulance dispatchers to dispatch the closest available ambulance View source Shortage of paramedics 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
Barbara Patterson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Barbara Patterson suffered a cerebral stroke at home on 1 January 2015, fell from a stair lift, and died at Wansbeck Hospital on 2 January 2015. The substantive concerns included the failure to provide timely CPR advice, a fault in the Pathways system relating to agonal breathing, ambulance dispatch and delayed arrival, and wider ambulance service capacity issues.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance crew handover at hospitals reducing ambulance availability
Wider context from the report “6. During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of the Pathways system to prompt CPR advice for patients with agonal breathing
Wider context from the report “2. During the inquest evidence was given that the Pathways system, a computerised system piloted in the North East and since rolled out for use by 6 other Healthcare Trusts nationally, has a fault in that it does not advise non clinical call handlers to issue CPR advice unless a patient has stopped breathing . This fails to recognise the need for CPR in cases of Agonal (heavy/noisy breathing which is insufficient to sustain life) . This fault was pointed out to Pathways by the Clinical Section Manager for North East Ambulance Service NHS Foundation Trust, prior to the latest update being installed in early 2014 (Update 9). Pathways refused to amend the system. That fault remains in place 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 Failure by call handlers to give timely CPR advice
Wider context from the report “1. The failure by the Call Handler to give timely advice in respect of CPR .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 arrival beyond the target response time
Wider context from the report “4. The target time for the arrival of the ambulance was 8 minutes, this was breached . The ambulance did not arrive for 15 minutes .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 by ambulance dispatchers to dispatch the closest available ambulance
Wider context from the report “3. The failure by the ambulance dispatcher to dispatch an ambulance closer to the deceased’s location
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Shortage of paramedics
Wider context from the report “5. During the inquest evidence was given that there is a national shortage of paramedics, which is particularly acute in the North East .
” 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 Pathways disputes that the system is faulty, stating it already identifies noisy breathing as requiring CPR advice.
Verbatim wording from the response “NHS Pathways has provided a response to your concerns (attached) which includes an overview of the CDSS system, how it is implemented, reviewed and updated and the amendments that are made to supporting information on breathing assessment. Noisy breathing is already identified as a major airway compromise that requires an emergency response and appropriate CPR advice. NHS Pathways believes the call-handler might have failed to pick up the cues which should have led to this advice being given.” Source location 2015-0198-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The eight-minute ambulance response target does not require every life-threatening call to receive a response within eight minutes.
Verbatim wording from the response “The target for an emergency ambulance response is that 75% of all Red 1 calls – the most serious, life-threatening category – receive a response within eight minutes. While ambulance services will always attempt to provide a response as soon as possible in life-threatening situations, the target recognises that it is unfortunately not always physically possible for ambulance services to respond to all Red 1 calls within eight minutes.” Source location 2015-0198-Response-by-Department-of-Health
Open published response
15 May 2015 George Richardson · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 3 Lack of a consolidated catheterisation record View source Failure to recognise previous catheterisation challenges and promote Urologist involvement View source Lack of national standards for safe and effective catheterisation skills View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
George Richardson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
George Richardson died in Sunderland Royal Hospital on 9 February 2015 after admission for urinary retention, during which he underwent several catheterisation procedures and suffered urethral trauma. The report raised concerns about repeated catheterisation by different individuals without a consolidated catheterisation record, meaning staff were not always aware of previous difficulties or prompted to involve a urologist.
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 consolidated catheterisation record
Wider context from the report “Catheterisation was carried out including attempts/manipulation on several occasions by different individuals without recourse to a consolidated catheterisation record . Individuals were not always aware of previous catheter challenges so as to promote the involvement of a Urologist.
The Trust are addressing their Catheterisation Policy but as there are 33,000 such procedures undertaken there each year, the skills required for safe and effective catheterisation may require national standards to be set.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise previous catheterisation challenges and promote Urologist involvement
Wider context from the report “Catheterisation was carried out including attempts/manipulation on several occasions by different individuals without recourse to a consolidated catheterisation record. Individuals were not always aware of previous catheter challenges so as to promote the involvement of a Urologist .
The Trust are addressing their Catheterisation Policy but as there are 33,000 such procedures undertaken there each year, the skills required for safe and effective catheterisation may require national standards to be set.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 standards for safe and effective catheterisation skills
Wider context from the report “Catheterisation was carried out including attempts/manipulation on several occasions by different individuals without recourse to a consolidated catheterisation record. Individuals were not always aware of previous catheter challenges so as to promote the involvement of a Urologist.
The Trust are addressing their Catheterisation Policy but as there are 33,000 such procedures undertaken there each year, the skills required for safe and effective catheterisation may require national standards to be set .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing national catheterisation guidance is considered sufficient, so additional national guidance is not currently required.
Verbatim wording from the response “Appropriate national guidance already exists. Ensuring staff know of it, and how and when to seek help where catheterisation proves problematic, is for hospital Trusts to action locally. For the future, should BAUS determine a need for further national advice, NHS England would support its dissemination.” Source location 2015-0189-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hospital Trusts are responsible for locally ensuring staff know the guidance and when to seek specialist help during difficult catheterisation.
Verbatim wording from the response “Appropriate national guidance already exists. Ensuring staff know of it, and how and when to seek help where catheterisation proves problematic, is for hospital Trusts to action locally. For the future, should BAUS determine a need for further national advice, NHS England would support its dissemination.” Source location 2015-0189-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation BAUS considers decisions about seeking senior help after repeated failed catheterisation attempts best addressed through local rather than national guidance.
Verbatim wording from the response “The British Association of Urological Surgeons (BAUS) has advised that the issue of when and how to seek more senior help following repeated failed attempts at catheterisation is best managed by local, rather than national, guidance.” Source location 2015-0189-Response-by-Department-of-Health
Open published response
Concerns raised 6 Failure to make detailed notes in detainees’ custody medical records View source Lack of verbal consultation between medical practitioners and custody sergeants about detainee concerns and observation levels View source Insufficient targeted training on drug and alcohol-related risks in custody View source Insufficient training emphasis on correct observation levels View source Lack of joint training exercises for medical practitioners, custody sergeants, custody detention officers and assistants View source Failure to specify detainee observation levels precisely View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Name not published · 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
The deceased was arrested on 2 October 2011 and held in custody, where he received prescribed methadone and medication for alcohol withdrawal. He was found unresponsive in his cell shortly before 9.00pm on 3 October 2011; the recorded medical cause of death was methadone intoxication, with alcohol withdrawal in a chronic alcoholic also identified. Concerns included communication between medical practitioners and custody staff, inconsistent observation levels, joint training, and training on drug and alcohol-related risks.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to make detailed notes in detainees’ custody medical records
Wider context from the report “1. That consideration be given to issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be a verbal consultation between the medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainee’s custody medical record .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 verbal consultation between medical practitioners and custody sergeants about detainee concerns and observation levels
Wider context from the report “1. That consideration be given to issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be a verbal consultation between the medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainee’s custody medical record.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 targeted training on drug and alcohol-related risks in custody
Wider context from the report “5. That training should include targeted training on the risks and dangers of drug and alcohol abuse, including methadone intoxication and alcohol withdrawal , particularly if the detainee is likely to be in custody for upwards of 24 hours.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 training emphasis on correct observation levels
Wider context from the report “3. That training should provide targeted emphasis on the correct levels of observation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 joint training exercises for medical practitioners, custody sergeants, custody detention officers and assistants
Wider context from the report “2. That consideration be given to the provision of joint training exercises for medical practitioners, custody sergeants and custody detention officers and assistants .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 specify detainee observation levels precisely
Wider context from the report “4. That consideration should be given to eliminating the phrase ‘continue observations at the current level’ and require that doctors and custody sergeants specify the level of observation precisely .
” Open source report
Concerns raised 1 Insufficient ambulance service resources to meet demand View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Alexander Murray · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Alexander Murray died on 8 February 2015 after developing myocarditis, suffering a cardiac arrest, and later dying in hospital despite treatment. The report identified insufficient ambulance resources following a second call as a concern, with delayed attendance and hospital arrival described in the circumstances.
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 resources to meet demand
Wider context from the report “That there were insufficient resources available for the London Ambulance service to meet the demand on the 8th February 2013 at 12.19
” 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 Individual ambulance trusts are responsible for ensuring ambulance resources are aligned with demand.
Verbatim wording from the response “Your report gave details of Mr Murray’s experiences following a call to London Ambulance Service on 8 February 2013. You were particularly concerned that there were insufficient ambulance resources available for the Service to meet the demand in the area at the time of the incident.” Source location 2015-0193-Response-by-Department-of-Health
Open published response
Concerns raised 1 Failure to perform routine blood sugar testing during long-term Clozapine treatment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Hana Aisha Abd Elhamid · 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
Hana Aisha Abd Elhamid was being treated with Clozapine for a mental health condition and developed diabetes, which was likely not identified because routine fasting blood tests were not carried out. She later required intubation for a diabetic coma, self-extubated and sustained airway injury, and died after subsequent breathing difficulties and treatment for a narrowed airway. The principal concerns were the failure to perform routine blood sugar testing and the resulting airway injury during treatment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to perform routine blood sugar testing during long-term Clozapine treatment
Wider context from the report “that this patient developed diabetes whilst on long term Clozapine treatment and that routine blood tests for sugar in the blood are likely to have prevented events , the need for intubation during treatment for a diabetic coma with resultant trachea injury following self -extubation, that directly led to the patients death
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the coroner’s report with NHS England.
Verbatim wording from the response “Your report has also been shared with NHS England. NHS England is currently working with the Royal College of Psychiatrists and the Prescribing Observatory for Mental Health to investigate patient safety incidents associated with Clozapine. Patient monitoring is included within the scope of this work. Should compelling evidence of system failures be found, then NHS England would support work to improve management and minimise harm.” Source location 2015-0194-Response-by-Department-of-Health
Open published response
11 May 2015 Margaret Elaine Wright · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1 Failure to telephone patients or their families for further information when a home visit is requested View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Margaret Elaine Wright · 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 Elaine Wright developed hepatitis C, liver cirrhosis and hepatocellular carcinoma following contaminated blood transfusions, and died in hospital on 23 December 2014 after her condition deteriorated following surgery. The principal concern was that the doctors’ practice did not telephone the patient or her family to obtain further information when a home visit was requested, and the doctor was unaware of her recent surgery because the practice had not received a discharge summary, resulting in a delayed visit.
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 telephone patients or their families for further information when a home visit is requested
Wider context from the report “(1) The Doctors did not at that time telephone patients or their families when a home visit had been requested to obtain further information about the patient’s situation. Had that happened in this case Mrs Wright would have received a priority visit, although there was no evidence that this would have affected the outcome. Evidence was given that since Mrs Wright’s death a system of a Doctor telephoning patients or their families prior to visiting had been introduced, both in the Doctors practice in question and in the local area. Evidence was given that this best practice should be drawn to the attention of the Secretary of State for Health in order to prevent future deaths.
” Open source report
Concerns raised 3 Risk of serious harm or death to babies from GBS infection View source Failure to routinely offer prophylactic intrapartum antibiotics to women with current or previous positive GBS tests View source Failure to routinely offer antenatal GBS screening to all pregnant women during the final weeks of pregnancy View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Baby Olsberg · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Baby Olsberg was born on 23 December 2013 and developed worsening symptoms in the hours after birth. Despite medical treatment and transfer to tertiary care, he suffered three cardiac arrests and died on 24 December 2013; blood cultures confirmed GBS infection. The concerns identified were the lack of routine antenatal GBS screening and routine prophylactic intrapartum antibiotics, and the resulting potential risk of serious harm or death to babies.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Risk of serious harm or death to babies from GBS infection
Wider context from the report “3. That GBS infection is a very serious illness and in the absence of a national screening and prophylactic treatment programme, babies are potentially being put at risk of harm/death .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely offer prophylactic intrapartum antibiotics to women with current or previous positive GBS tests
Wider context from the report “2. That prophylactic intrapartum antibiotics are not routinely offered to all women who test positive for GBS (or have done so in the past) .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 offer antenatal GBS screening to all pregnant women during the final weeks of pregnancy
Wider context from the report “1. That antenatal screening for GBS is not routinely offered by the NHS, to all pregnant women, during the final weeks of pregnancy .
” 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 Universal antenatal GBS screening is not considered necessary because evidence does not show its benefits outweigh its harms.
Verbatim wording from the response “evidence for programmes against a set of internationally recognised criteria. In the case of GBS carriage in pregnancy, the current evidence does not support universal screening.” Source location 2015-0177-Response-by-Department-of-Health
Open published response
20 Apr 2015 Andrew Ralph Mitchell Farrow · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 1 Unavailability of hospital beds for patients requiring admission at Green Lane Hospital Devizes 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
Andrew Ralph Mitchell Farrow · 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
Andrew Ralph Mitchell Farrow died at home on 7 July 2014 as a result of self-administered acute codeine and alcohol toxicity. He had expressed a wish to be admitted to hospital for his own safety, and the concern was that no beds would have been available at Green Lane Hospital Devizes if admission had been needed.
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 hospital beds for patients requiring admission at Green Lane Hospital Devizes
Wider context from the report “He was known to have suicidal ideation but no actual plan had been formulated. I did not find that he ought to have been admitted. My concern however is that had he needed admitting it is apparent no beds would have been available at Green Lane Hospital Devizes when an enquiry was made on 6 July 2014 by North Wiltshire Intensive Services.
” Open source report
16 Apr 2015 Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 28 Failure of the youth diversion project to provide diversion before criminal justice processing View source Failure to record and explain incomplete medical assessments View source Failure to return completed Appropriate Adult forms to Social Services View source Interagency confusion about safeguarding roles and access to information View source Failure to initiate youth offending and mental health monitoring after case transfer View source Failure to pass complete incident information to attending officers View source Inconsistent safeguarding functions across Manchester Multi-Agency Safeguarding Hubs View source Insufficient availability of accommodation for children under 17 View source Insufficient recording of safeguarding information by Appropriate Adults View source Failure of youth offending teams to transfer and oversee cases after relocation View source Failure to assess police information when selecting an Appropriate Adult View source Lack of legally required accommodation for 17-year-olds refused bail View source Failure to make safeguarding referrals from custody medical information View source Failure to record safeguarding intelligence on nominal profiles View source Failure to conduct police database checks on standard-risk DASH referrals View source Failure to route domestic violence cases involving 17-year-old children to child protection review View source Lack of shared understanding between police and MEDACS about requested medical assessments View source Lack of interagency understanding for sharing safeguarding information between police and CPS View source Failure to provide Appropriate Adults with relevant custody risk information View source Failure to provide differentiated mental health assessments for children in custody View source Failure to document information provided to MEDACS before medical assessments View source Failure to check and update Prisoner Escort Records before release View source Custody handovers dependent on officers’ and staff’s unpaid free time View source Lack of consistent child safeguarding coverage across Manchester local authorities View source Lack of clear officer guidance for raising safeguarding concerns View source Unclear referral routes for non-criminal safeguarding concerns View source Lack of a process for recording safeguarding concerns View source Lack of a non-criminal safeguarding policy View source See 25 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
Kesia Lena Mary Leatherbarrow · 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
Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.
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 the youth diversion project to provide diversion before criminal justice processing
Wider context from the report “The court heard evidence that in Tameside this signposting is only taking place to the mental health services once the young person has been processed through the Criminal Justice System and is not in fact acting as a diversion pathway . There was no evidence from those working in custody that any consideration was given to this scheme for Kesia and there appeared to be little knowledge of the scheme .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to record and explain incomplete medical assessments
Wider context from the report “It was clear that a medical assessment could not be completed and in these circumstances this should be fully explained to the police and the record endorsed accordingly rather than simply endorsing that someone is fit to be detained/interviewed or transferred .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 return completed Appropriate Adult forms to Social Services
Wider context from the report “Evidence from Tameside Social Services indicated that they did not receive the completed form in relation to Kesia and that it was not unusual not to receive the completed forms in any cases.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Interagency confusion about safeguarding roles and access to information
Wider context from the report “Having heard the evidence the Court felt that there was a degree of confusion and misunderstanding between all the agencies as to their roles , what they are able and not able to do and also where to access important and effective information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to initiate youth offending and mental health monitoring after case transfer
Wider context from the report “This did not occur as the file had not been processed at the time of Kesia’s death but also because of the confusion between the Youth Offending Teams involved with Kesia which meant she was never picked up by Tameside . The plan that Kesia should be monitored for any interim changes in her risk did not therefore 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 Failure to pass complete incident information to attending officers
Wider context from the report “The Court heard evidence as to the failure to pass on complete information to the officers who then subsequently attended on Kesia including on one occasion the fact that it had been communicated that she had a knife . The court heard evidence that the failure to pass on important information could impact on the safety of the officers and others and also lead to missed opportunities for safeguarding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistent safeguarding functions across Manchester Multi-Agency Safeguarding Hubs
Wider context from the report “This was not the system in Manchester and the Court heard evidence that the development of MASHs across Manchester is still ongoing. The Court heard evidence that in Manchester different hubs work differently with different agendas – some relate to domestic violence only and not all of them deal with safeguarding of children .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of accommodation for children under 17
Wider context from the report “The Inquest heard that across Greater Manchester it is estimated that, until recently, in only 10% of cases where the police requested such a service from a local authority a bed was available . Attempts are being made to address this issue but at present the figure remains approximately 20% and the Inquest heard evidence that this was, “not good enough”.
Again the facts heard at this Inquest seem to suggest that children younger than 17 are at risk of being held in custody longer than necessary due to a lack of appropriate facilities . The court heard evidence that the police are in the undesirable position of having to decide whether to detain someone (potentially unlawfully) or release them when they feel it may be unsafe 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 Insufficient recording of safeguarding information by Appropriate Adults
Wider context from the report “The quality of the information given by the appropriate adult on the completed form was insufficient in light of all the information which had been made available to her about Kesia and the behaviour she had witnessed. Important information such as the threat made by Kesia was not placed onto the form
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 youth offending teams to transfer and oversee cases after relocation
Wider context from the report “There was a failure by Lancashire to note her move which led to a delay in her case being transferred, but in addition there was a failure in the communications with Tameside for each team to understand what was being requested and to have oversight of the situation. This led to a lack of involvement with Kesia and a proposal to breach her. It also meant that no effective work was being carried out with her and a missed opportunity to recognise her developing situation in terms of her lack of residence and drug use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 police information when selecting an Appropriate Adult
Wider context from the report “It was not her understanding of the system in place that she should be assessing the information given to her by the police to consider whether it was more suitable for the attendance of a Social Worker.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 legally required accommodation for 17-year-olds refused bail
Wider context from the report “There remains no legal requirement for local authorities to provide accommodation for 17 year olds who will then have to remain in police custody if bail is refused. The result is that 17 year old children risk being kept in custody for longer than necessary if there is nowhere suitable for them to be bailed to.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to make safeguarding referrals from custody medical information
Wider context from the report “Similarly the Court heard that no safeguarding referral was made about Kesia despite information about her self-harming, drug and alcohol use .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to record safeguarding intelligence on nominal profiles
Wider context from the report “No intelligence was placed on Kesia’s nominal profile despite a number of concerning contacts with her by officers . It is a core function of the police to submit such intelligence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct police database checks on standard-risk DASH referrals
Wider context from the report “when a Domestic Abuse, Stalking and Harassment form (DASH) is submitted to the PPI unit, where the risk level is standard then no checks on the Police National Computer or the Police National Database are carried out . The rationale for this was not clear although DC Evans indicated this may be due to the volume of work. Clearly the PNC can hold vital information about a potential offender .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 route domestic violence cases involving 17-year-old children to child protection review
Wider context from the report “For domestic violence incidents the closing code relates to people over the age of 16 as being adults. This means that the case is not then automatically passed through to the Child Protection Team within Greater Manchester Police for a review even if one of the people involved is still a child - i.e. is 17 years of age.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of shared understanding between police and MEDACS about requested medical assessments
Wider context from the report “It was apparent to the Court that the expectations of the police as to the precise medical assessment being carried out and the conclusions of the assessment may not always be the same as the expectations and understanding of MEDACS .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 interagency understanding for sharing safeguarding information between police and CPS
Wider context from the report “There was a lack of understanding between GMP and the CPS as to how such important information should be shared between agencies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Appropriate Adults with relevant custody risk information
Wider context from the report “She was not advised that Kesia had been assessed as intoxicated and arrival, nor that she had been seen by MEDACS , nor that she had threatened to jump off a bridge on her release.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 differentiated mental health assessments for children in custody
Wider context from the report “The Court also heard evidence that the same medical assessment is carried out for every detained person in custody regardless of whether that is a 17 year old child with mental health difficulties or a 69 year old man with a heart condition. There is no difference in the mental health assessments for children as opposed to adults .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to document information provided to MEDACS before medical assessments
Wider context from the report “there was no clarity as to whether this included previous risk assessments , whether this was a complete record and there was no recorded evidence to indicate what information had been passed to MEDACS by the police and who had provided the information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to check and update Prisoner Escort Records before release
Wider context from the report “The Prisoner Escort Record form was completed over 12 hours prior to Kesia leaving police custody. It was not checked or amended prior to her release and it failed to contain crucial information indicating that whilst in custody Kesia had made a threat to jump from a bridge.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Custody handovers dependent on officers’ and staff’s unpaid free time
Wider context from the report “The system at present relies on officers and staff attending work early and sometimes staying late after a 12 hour shift to provide a handover. Whilst it is clear there would need to be some overlap in the times people are on duty, the Court heard evidence as to the quality of the handovers which is clearly impacted by the fact that this crucial part of the information sharing process relies entirely on the free-time of officers and staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent child safeguarding coverage across Manchester local authorities
Wider context from the report “This will mean that there is a lack of consistency in approach across the different local authorities in Manchester as to what will be dealt with. Worryingly some will not deal with the safeguarding of children
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clear officer guidance for raising safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unclear referral routes for non-criminal safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for recording safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns . There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 non-criminal safeguarding policy
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal . There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” Open source report
8 Apr 2015 Aleysha Martine Karla McLoughlin · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 6 Unavailability of a shared formal pathway of help for young people who resist engagement View source Failure to hold urgent multi-agency discussions involving all relevant agencies for young people at risk of self-harm View source Insufficient agency capacity to address self-harm appropriately View source Lack of a system encouraging young people to report another young person’s self-harm to those able to help View source Omission of blood pressure checks from annual health checks for looked after children View source Failure of training for professionals working with young people to support recognition and discovery of self-harm View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Aleysha Martine Karla McLoughlin · 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
Aleysha Martine Karla McLoughlin, aged 16, died by hanging at her foster home on 3 April 2014 after a history of self-harm, overdoses and assessed ongoing risk of impulsive self-harm. The concerns included training for professionals to recognise self-harm, systems for sharing information when young people self-harm, urgent multi-agency discussions including mental health services, and a formal support pathway for young people who resist engagement.
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 a shared formal pathway of help for young people who resist engagement
Wider context from the report “(4) That it should be considered that a particular pathway of help for young people who resist engagement should be developed. There was no evidence that any such formal pathway had been shared at the present time .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 hold urgent multi-agency discussions involving all relevant agencies for young people at risk of self-harm
Wider context from the report “(3) That it should be considered that systems such as those now being developed in Bolton should be further developed so as to ensure that multi agency discussions involving all relevant agencies are held urgently for those at risk of self harm and particularly for those who do not engage . Evidence was given that meetings concerning Aleysha Martine Karla McLoughlin did not include the Child and Adolescent Mental Health Services although evidence was given that their input would have been valuable.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 agency capacity to address self-harm appropriately
Wider context from the report “(5) That a review of the capacity of the agencies involved in helping young people who are self harming to address those matters appropriately should be considered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a system encouraging young people to report another young person’s self-harm to those able to help
Wider context from the report “(2) That it should be considered that additional information and encouragement could be offered to young people to inform those able to help for example teachers, nurses, health professionals etc. when a young person becomes aware that another young person is self harming. The shocking self harm to which Aleysha Martine Karla McLoughlin had subjected herself was only revealed when a school friend brought it to the attention of a teacher. There was no evidence that there was any system in place to encourage the passing of such information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Omission of blood pressure checks from annual health checks for looked after children
Wider context from the report “(1) That it should be considered that the system of training for those working with young people, including teachers, school nurses, foster carers, social workers, mental health workers and medical nurses and doctors should be reviewed so as to ensure that these professionals should be alert for signs of self harm and should take opportunities to discover themselves so that those harming themselves can be offered help and support. By way of example evidence was given at the Inquest that the annual health check offered to looked after children did not include a blood pressure check . If a blood pressure check was included this would provide an opportunity for signs of self harm to be revealed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 training for professionals working with young people to support recognition and discovery of self-harm
Wider context from the report “(1) That it should be considered that the system of training for those working with young people, including teachers, school nurses, foster carers, social workers, mental health workers and medical nurses and doctors should be reviewed so as to ensure that these professionals should be alert for signs of self harm and should take opportunities to discover themselves so that those harming themselves can be offered help and support. By way of example evidence was given at the Inquest that the annual health check offered to looked after children did not include a blood pressure check. If a blood pressure check was included this would provide an opportunity for signs of self harm to be revealed.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations