Concerns raised 4 Difficulty for Trusts to change guidance without external guidance improvement View source Use of misleading and clinically inappropriate ‘gentle’ traction terminology View source Lack of operational definitions for instrumental-delivery terminology View source Ambiguity in guidance on when to abandon instrumental delivery View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Thomas Beaty · 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
Thomas Beaty was born by emergency caesarean section after an abandoned instrumental delivery on 11 April 2014. At 26 hours of age, he suffered a catastrophic head injury, hypovolaemic shock and hypoxic brain ischaemia, and died. The report raised concerns that guidance on instrumental delivery was ambiguous and potentially open to misinterpretation, including unclear terminology and misleading guidance about traction.
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 Difficulty for Trusts to change guidance without external guidance improvement
Wider context from the report “1. Instrumental Delivery – the Court heard how local/national protocols and
training programmes are routinely based on guidance issued by the Royal College of
Obstetricians and NICE. The guidance in use at the time of Thomas’ birth was found to be
ambiguous, misleading and potentially open to misinterpretation.
A key example was:
‘…When to abandon the procedure:
• No evidence of progressive descent with each pull
• No evidence of imminent birth following 3 pulls of a correctly placed instrument by
an experienced operator…’
The first point by implication must mean that where there is no descent with the first pull, then the
procedure ought to be abandoned, yet the second point suggests abandonment after a 3rd traction.
2. Terminology - The RCOG Guidance did not provide operational definitions for words such
as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’
case, as it had a bearing on the decision making processes applied during the course of the
forceps delivery.
3. Traction - The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s
protocol was misleading and not in line with the RCOG Guidance. The clinical evidence
suggested that in most (if not all) cases mild to moderate traction is routinely applied by
clinicians in order to ensure safe and successful instrumental delivery. Whilst it was
accepted that this was often subjective, the term ‘gentle’ was clinically out with.
4. Development of Trust Guidance – it is difficult for Trusts to change their guidance until
and unless there is a change/material improvement in the Guidance issued by the RCOG.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Use of misleading and clinically inappropriate ‘gentle’ traction terminology
Wider context from the report “1. Instrumental Delivery – the Court heard how local/national protocols and
training programmes are routinely based on guidance issued by the Royal College of
Obstetricians and NICE. The guidance in use at the time of Thomas’ birth was found to be
ambiguous, misleading and potentially open to misinterpretation.
A key example was:
‘…When to abandon the procedure:
• No evidence of progressive descent with each pull
• No evidence of imminent birth following 3 pulls of a correctly placed instrument by
an experienced operator…’
The first point by implication must mean that where there is no descent with the first pull, then the
procedure ought to be abandoned, yet the second point suggests abandonment after a 3rd traction.
2. Terminology - The RCOG Guidance did not provide operational definitions for words such
as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’
case, as it had a bearing on the decision making processes applied during the course of the
forceps delivery.
3. Traction - The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s
protocol was misleading and not in line with the RCOG Guidance. The clinical evidence
suggested that in most (if not all) cases mild to moderate traction is routinely applied by
clinicians in order to ensure safe and successful instrumental delivery. Whilst it was
accepted that this was often subjective, the term ‘gentle’ was clinically out with.
4. Development of Trust Guidance – it is difficult for Trusts to change their guidance until
and unless there is a change/material improvement in the Guidance issued by the RCOG.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 operational definitions for instrumental-delivery terminology
Wider context from the report “1. Instrumental Delivery – the Court heard how local/national protocols and
training programmes are routinely based on guidance issued by the Royal College of
Obstetricians and NICE. The guidance in use at the time of Thomas’ birth was found to be
ambiguous, misleading and potentially open to misinterpretation.
A key example was:
‘…When to abandon the procedure:
• No evidence of progressive descent with each pull
• No evidence of imminent birth following 3 pulls of a correctly placed instrument by
an experienced operator…’
The first point by implication must mean that where there is no descent with the first pull, then the
procedure ought to be abandoned, yet the second point suggests abandonment after a 3rd traction.
2. Terminology - The RCOG Guidance did not provide operational definitions for words such
as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’
case, as it had a bearing on the decision making processes applied during the course of the
forceps delivery.
3. Traction - The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s
protocol was misleading and not in line with the RCOG Guidance. The clinical evidence
suggested that in most (if not all) cases mild to moderate traction is routinely applied by
clinicians in order to ensure safe and successful instrumental delivery. Whilst it was
accepted that this was often subjective, the term ‘gentle’ was clinically out with.
4. Development of Trust Guidance – it is difficult for Trusts to change their guidance until
and unless there is a change/material improvement in the Guidance issued by the RCOG.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in guidance on when to abandon instrumental delivery
Wider context from the report “1. Instrumental Delivery – the Court heard how local/national protocols and
training programmes are routinely based on guidance issued by the Royal College of
Obstetricians and NICE. The guidance in use at the time of Thomas’ birth was found to be
ambiguous, misleading and potentially open to misinterpretation.
A key example was:
‘…When to abandon the procedure:
• No evidence of progressive descent with each pull
• No evidence of imminent birth following 3 pulls of a correctly placed instrument by
an experienced operator…’
The first point by implication must mean that where there is no descent with the first pull, then the
procedure ought to be abandoned, yet the second point suggests abandonment after a 3rd traction.
2. Terminology - The RCOG Guidance did not provide operational definitions for words such
as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’
case, as it had a bearing on the decision making processes applied during the course of the
forceps delivery.
3. Traction - The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s
protocol was misleading and not in line with the RCOG Guidance. The clinical evidence
suggested that in most (if not all) cases mild to moderate traction is routinely applied by
clinicians in order to ensure safe and successful instrumental delivery. Whilst it was
accepted that this was often subjective, the term ‘gentle’ was clinically out with.
4. Development of Trust Guidance – it is difficult for Trusts to change their guidance until
and unless there is a change/material improvement in the Guidance issued by the RCOG.
” 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 Send the coroner’s report to the RCOG to communicate the concerns about ambiguity in its maternity guidance.
Verbatim wording from the response “You had a number of concerns about the guidance issued by the Royal College of Obstetricians and Gynaecologists (RCOG), which the inquest found to be ambiguous, misleading and potentially open to misinterpretation, giving as the example that the RCOG guidance did not provide operational definitions for words such as ‘imminent’ (vis a vis birth) or ‘crowning’.” Source location 2015-0130-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 RCOG is responsible for addressing concerns about its professional guidance.
Verbatim wording from the response “While local maternity and neonatal care providers must determine how best to deliver services in their area, in doing so we would expect them to give due regard to RCOG and other professional guidance. To this end, a copy of your report has been sent to the RCOG to make them aware of the concerns you have raised and I understand that they have responded to you directly.” Source location 2015-0130-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 Local maternity and neonatal providers are responsible for determining how services should be delivered in their areas.
Verbatim wording from the response “While local maternity and neonatal care providers must determine how best to deliver services in their area, in doing so we would expect them to give due regard to RCOG and other professional guidance. To this end, a copy of your report has been sent to the RCOG to make them aware of the concerns you have raised and I understand that they have responded to you directly.” Source location 2015-0130-Response-by-Department-of-Health
Open published response
Concerns raised 3 Failure to implement nationally a policy limiting police attendance at mental health wards to threats to staff or disorder View source Absence of a national multi-agency crisis team system for people in mental health crisis View source Lack of national training and understanding of how best to treat acute behavioural disturbance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kingsley Burrell · 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
Kingsley Burrell died on 31 March 2011 after being restrained and transported between mental health and hospital settings following an acute mental health disturbance. The inquest found that the covering over his head, unreasonable periods of restraint, delay in resuscitation and neglect contributed to his death. Concerns included inconsistent national understanding of acute behavioural disturbance, the absence of a nationally implemented crisis-team system, and non-nationally consistent policies for managing patients between services during a crisis.
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 implement nationally a policy limiting police attendance at mental health wards to threats to staff or disorder
Wider context from the report “(3) This case has resulted in a multi-agency review of how patients are managed between the services when crisis occurs. A new conveying of patients policy has been devised. Critically police now only attend a mental health ward if there was a patient who is threatening staff or there is disorder on the ward. My concern is that this is not reflected nationally . Chief Inspector ███████ at West Midlands Police can provide full details of the policy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of a national multi-agency crisis team system for people in mental health crisis
Wider context from the report “(2) The West Midlands area now have a crisis team that works with people who are in a mental health crisis . This involves a mental health worker and ambulance crew working together with the Police to try to help patients with acute mental health disorders . My concern is that this is not a national system . Chief Inspector ███████ at West Midlands Police can provide full details 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 Lack of national training and understanding of how best to treat acute behavioural disturbance
Wider context from the report “(1) Medical evidence at the inquest confirmed that Mr Burrell was suffering from acute behaviour disturbance. As a result he continued to struggle against restraint. Patients with this condition are at risk of death through prolonged restraint and struggle against restraint. Most training in relation to restraint deaths focuses on positional asphyxia. Position in this case was not a major consideration. It was clear from the inquest that there was a lack of understanding of how to treat someone with an acute behavioural disturbance . Minimising the period of restraint is key. West Midlands Police have undertaken considerable work and training of staff concerning this condition. My concern is that this has not been rolled out nationally and therefore many other forces will not understand the implications of this condition and how best to treat it . I suggest contact is made with Chief Inspector Russell at WMP for full information on the changes made in the West Midlands area.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop further guidance and training with police, professional bodies and mental health trusts to support local restraint protocols.
Verbatim wording from the response “Both the Code and the guidance make clear that all types of restraint should be used for the least amount of time needed to manage risks to the individual and others. Department officials continue to work with the police, the Royal Colleges of Nurses and Psychiatrists, and Mental Health Trusts to develop further guidance and training to support local protocols, so that all partners are clear about what should happen in these circumstances.” Source location 2015-0472-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the Crisis Care Concordat to establish cross-sector expectations for local mental health crisis responses.
Verbatim wording from the response “The Department published the Crisis Care Concordat in 2014 to ensure that anyone experiencing a mental health crisis receives the right support in the right place. The Concordat is a cross-sector agreement which ensures that local areas provide the” Source location 2015-0472-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the Mental Health Act Code of Practice to provide statutory guidance on restrictive practices and restraint.
Verbatim wording from the response “On restraint, both statutory and non-statutory guidance exists. The Mental Health Act 1983 Code of Practice (the Code) was revised in 2015 and provides statutory guidance on the appropriate use of restrictive practices that protect the dignity and safety of patients. The Code is clear that any restraint should be the least restrictive,” Source location 2015-0472-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fund street triage pilot schemes providing mental health professionals’ on-the-spot advice to police during possible mental health crises.
Verbatim wording from the response “The Department has also funded a number of street triage pilot schemes where mental health professionals provide on the spot advice to police when dealing with people with possible mental health problems. These pilots are currently being evaluated so that this approach can be rolled out more widely.” Source location 2015-0472-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 local policies and crisis plans provide the arrangements for cross-agency mental health crisis responses rather than a single national system.
Verbatim wording from the response “You highlight the need for cross-agency working to safely manage people being moved between services when a mental health crisis occurs and when police attend a health setting. The Code states local policies should be in place between providers, the police and other agencies with protocols covering all aspects of the use of section 135 and 136 powers. Sections 135 and 136 give the police powers to temporarily move people, who appear to be suffering from a mental disorder, and who need urgent care, to a ‘place of safety’ so that a mental health assessment can be carried out and appropriate arrangements made for care. Local policies should include arrangements for police attend a health-based setting and transporting people between places of safety.” Source location 2015-0472-Response-by-Department-of-Health
Open published response
Concerns raised 3 Large-volume helium canisters View source Failure to attach modified control valves restricting helium gas release volume View source Lack of controls on individual helium canister purchase quantities View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brenda Kathryn Gabrielle Leyland · 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
Brenda Leyland was found deceased in a hotel room on 4 October 2014 after buying helium canisters to end her life; the inquest concluded suicide. The concerns were the free availability of helium canisters, the lack of controls on purchase quantities, their large volume, and the absence of a modified control valve to restrict gas release.
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 Large-volume helium canisters
Wider context from the report “(1) That helium gas is freely available in canisters and there appears to be no controlling measures on how many canisters can be bought by an individual.
(2) The size of the helium canisters are of large volume .
(3) There is no modified control valve attached to the canisters which would restrict the volume of gas being released.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 attach modified control valves restricting helium gas release volume
Wider context from the report “(1) That helium gas is freely available in canisters and there appears to be no controlling measures on how many canisters can be bought by an individual.
(2) The size of the helium canisters are of large volume.
(3) There is no modified control valve attached to the canisters which would restrict the volume of gas being released .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 controls on individual helium canister purchase quantities
Wider context from the report “(1) That helium gas is freely available in canisters and there appears to be no controlling measures on how many canisters can be bought by an individual .
(2) The size of the helium canisters are of large volume.
(3) There is no modified control valve attached to the canisters which would restrict the volume of gas being released.
” 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 Evidence that even small amounts of helium can cause death means controls on availability would be ineffective.
Verbatim wording from the response “Having reviewed the response in the case of Matthew Satterthwaite, which was sent to HM Coroner Mr Nigel Meadows, I note that the examples given showed that even small amounts of helium can be sufficient to cause death, rendering controls on availability ineffective. This has led to a number of options to address the issues you raise being considered and discarded.” Source location 2015-0112-Response-by-Department-of-Health
Open published response
Concerns raised 2 Transfer of acute psychiatric patients when no bed is available View source Use of CRHTT as a filter preventing patients in need of a bed from accessing a bed View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ronald Gittens · 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
Ronald Gittens was taken to hospital, assessed for an informal psychiatric admission and transferred while waiting for a bed, but left before admission. He was later found at home having hanged himself. The principal concerns were the transfer of acute psychiatric patients when no bed is available and the use of CRHTT as a filter for patients needing a bed.
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 Transfer of acute psychiatric patients when no bed is available
Wider context from the report “The transfer of acute psychiatric patients when no bed is available and
The use of CRHTT as a filter to prevent patients in need of a bed from having access to a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Use of CRHTT as a filter preventing patients in need of a bed from accessing a bed
Wider context from the report “The transfer of acute psychiatric patients when no bed is available and
The use of CRHTT as a filter to prevent patients in need of a bed from having access to a bed.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The local mental health trust is responsible for responding to concerns about patient transfers and crisis home treatment arrangements.
Verbatim wording from the response “You have also sent your report to the Barnet, Enfield and Haringey Mental Health Trust. The concerns you raise are properly matters for the local Trust and I would expect them to respond appropriately to you. We give Trusts the freedom and discretion to arrange these matters in ways that best meet the needs of patients. However we insist that all patients receive timely, high-quality care. Where that does not happen, as in this case, Trusts must take action to put things right.” Source location 2015-0117-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 Decision-making on inter-trust transfers of at-risk psychiatric patients rests with the local NHS, not the Department of Health.
Verbatim wording from the response “I appreciate that the issue of inter-trust transfers of at-risk psychiatric patients is indeed one relevant to all Mental Health NHS Trusts. However, the responsibility for decision making in this area resides with the local NHS rather than the Department of Health.” Source location 2015-0117-Response-by-Department-of-Health
Open published response
Concerns raised 2 Failure of hospitals to inform General Practitioners of GDH positive results View source Lack of awareness of the significance of GDH positive results for future antibiotic prescribing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mary Magdalene Marshall · 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
Mary Magdalene Marshall died in hospital after admission with an incarcerated inguinal hernia and small bowel obstruction, later developing pneumonia and confirmed Clostridium Difficile infection. The principal concerns were limited awareness of GDH-positive results among healthcare practitioners, communication of those results to primary care, and their significance when prescribing antibiotics.
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 hospitals to inform General Practitioners of GDH positive results
Wider context from the report “ii. The evidence indicated that there was a lack of awareness, in general, of the importance of GDH positive results in relation to the future prescription of antibiotics and the risk of the development of Clostridium Difficile infection. Furthermore there is a lack of awareness amongst General Practitioners in relation to GDH positive results.
iii. The evidence indicated that there were Hospital Trusts in the North West that did not inform General Practitioners of GDH positive results and it is believed that a similar problem may exist Nationwide .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the significance of GDH positive results for future antibiotic prescribing
Wider context from the report “ii. The evidence indicated that there was a lack of awareness, in general, of the importance of GDH positive results in relation to the future prescription of antibiotics and the risk of the development of Clostridium Difficile infection . Furthermore there is a lack of awareness amongst General Practitioners in relation to GDH positive results .
iii. The evidence indicated that there were Hospital Trusts in the North West that did not inform General Practitioners of GDH positive results and it is believed that a similar problem may exist Nationwide.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver national antimicrobial-resistance workshops and a national C. difficile study day promoting testing and appropriate antibiotic prescribing.
Verbatim wording from the response “Nevertheless, appropriate information relating to a patient’s CDI status is essential for informing the most appropriate care and treatment. Nationally work is already being undertaken to ensure that this is recognised. As part of NHS England’s Antimicrobial Resistance (AMR) work programme, work has been undertaken to promote the importance of C. diff testing. This has been achieved in part by the delivery of three national AMR workshops and a national clostridium difficile study day. All materials will be made available on the NHS England Patient Safety Domain webpage” Source location 2015-0084-Response-by-Department-of-Health1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with partners to develop wider understanding of C. difficile testing and the implications of results, including GDH testing.
Verbatim wording from the response “To ensure this work is developed further, and in light of the recommendations made, NHS England will work with partners to continue to explore ways to develop a wider understanding of C. diff testing and the implications of the results, including but not limited to GDH testing.” Source location 2015-0084-Response-by-Department-of-Health1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore methods to support local health communities in reporting and sharing patients’ C. difficile status.
Verbatim wording from the response “Methods to support local health communities in the reporting and sharing of information in relation to a patient’s CDI status will also be explored. More widely, NHS England is already working on ideas for improving the provision of information between hospitals and primary care upon patient discharge. This will be informed by examples of best practice implemented locally and by consulting with relevant partners and subject matter experts to determine how information should be disseminated.” Source location 2015-0084-Response-by-Department-of-Health1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop hospital-to-primary-care information sharing on patient discharge, informed by local best practice and consultation with relevant partners and experts.
Verbatim wording from the response “Methods to support local health communities in the reporting and sharing of information in relation to a patient’s CDI status will also be explored. More widely, NHS England is already working on ideas for improving the provision of information between hospitals and primary care upon patient discharge. This will be informed by examples of best practice implemented locally and by consulting with relevant partners and subject matter experts to determine how information should be disseminated.” Source location 2015-0084-Response-by-Department-of-Health1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make national workshop and study-day materials available on the NHS England Patient Safety Domain webpage.
Verbatim wording from the response “Nevertheless, appropriate information relating to a patient’s CDI status is essential for informing the most appropriate care and treatment. Nationally work is already being undertaken to ensure that this is recognised. As part of NHS England’s Antimicrobial Resistance (AMR) work programme, work has been undertaken to promote the importance of C. diff testing. This has been achieved in part by the delivery of three national AMR workshops and a national clostridium difficile study day. All materials will be made available on the NHS England Patient Safety Domain webpage” Source location 2015-0084-Response-by-Department-of-Health1
Open published response
3 Mar 2015 Paige Louise Bell · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 8 Failure to ensure medical personnel have immediate electronic access to complete patient notes View source Failure to include the RIO reference on observation record front sheets View source Insufficient time for staff to complete records promptly View source Insufficient space for commentary in observation records View source Unavailability of relevant, up-to-date and accurate information from notes View source Failure of observation forms to accommodate changes in observation rationale View source Failure of observation records to clearly require completion of all parts View source Difficulties navigating records to establish event chronology and decision rationale View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paige Louise Bell · 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
Paige Louise Bell, aged 20, died at Sunderland Royal Hospital on 14 August 2014 after applying a ligature to her neck following an episode of self-harm. The inquest identified contradictions in the observation policy as a contributing factor. Concerns included case notes not being held together or fully transferred with the patient, and the need for consistent observation policies and updated guidance on managing patients with Borderline Personality Disorder.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure medical personnel have immediate electronic access to complete patient notes
Wider context from the report “The case notes were not held in one place and not all transferred with the patient . I wondered if there were any ongoing plans to allow medical personnel to have immediate access to all notes electronically rather than notes following the patient as they will contain essential information for a patient’s healthcare 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 include the RIO reference on observation record front sheets
Wider context from the report “Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): -
• The new Observation record does not allow sufficient space for commentary.
• The front sheet does not appear to have the RIO reference.
• On the face of the document it is not clear that staff must complete all parts of the record.
• If the rationale for observations were to change then the form needs to provide for that.
• It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form.
• If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed.
No doubt there will be full training undertaken with regard to the new Policy.
I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes.
All staff need time to be able to complete such records in a more timely way.
That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety.
I also enclose a copy of my report to 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 Insufficient time for staff to complete records promptly
Wider context from the report “Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): -
• The new Observation record does not allow sufficient space for commentary.
• The front sheet does not appear to have the RIO reference.
• On the face of the document it is not clear that staff must complete all parts of the record.
• If the rationale for observations were to change then the form needs to provide for that.
• It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form.
• If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed.
No doubt there will be full training undertaken with regard to the new Policy.
I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes.
All staff need time to be able to complete such records in a more timely way.
That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety.
I also enclose a copy of my report to 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 Insufficient space for commentary in observation records
Wider context from the report “Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): -
• The new Observation record does not allow sufficient space for commentary.
• The front sheet does not appear to have the RIO reference.
• On the face of the document it is not clear that staff must complete all parts of the record.
• If the rationale for observations were to change then the form needs to provide for that.
• It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form.
• If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed.
No doubt there will be full training undertaken with regard to the new Policy.
I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes.
All staff need time to be able to complete such records in a more timely way.
That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety.
I also enclose a copy of my report to 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 Unavailability of relevant, up-to-date and accurate information from notes
Wider context from the report “Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): -
• The new Observation record does not allow sufficient space for commentary.
• The front sheet does not appear to have the RIO reference.
• On the face of the document it is not clear that staff must complete all parts of the record.
• If the rationale for observations were to change then the form needs to provide for that.
• It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form.
• If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed.
No doubt there will be full training undertaken with regard to the new Policy.
I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes .
All staff need time to be able to complete such records in a more timely way.
That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety.
I also enclose a copy of my report to 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 of observation forms to accommodate changes in observation rationale
Wider context from the report “Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): -
• The new Observation record does not allow sufficient space for commentary.
• The front sheet does not appear to have the RIO reference.
• On the face of the document it is not clear that staff must complete all parts of the record.
• If the rationale for observations were to change then the form needs to provide for that.
• It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form.
• If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed.
No doubt there will be full training undertaken with regard to the new Policy.
I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes.
All staff need time to be able to complete such records in a more timely way.
That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety.
I also enclose a copy of my report to 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 of observation records to clearly require completion of all parts
Wider context from the report “Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): -
• The new Observation record does not allow sufficient space for commentary.
• The front sheet does not appear to have the RIO reference.
• On the face of the document it is not clear that staff must complete all parts of the record.
• If the rationale for observations were to change then the form needs to provide for that.
• It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form.
• If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed.
No doubt there will be full training undertaken with regard to the new Policy.
I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes.
All staff need time to be able to complete such records in a more timely way.
That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety.
I also enclose a copy of my report to 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 Difficulties navigating records to establish event chronology and decision rationale
Wider context from the report “Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): -
• The new Observation record does not allow sufficient space for commentary.
• The front sheet does not appear to have the RIO reference.
• On the face of the document it is not clear that staff must complete all parts of the record.
• If the rationale for observations were to change then the form needs to provide for that.
• It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form.
• If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed.
No doubt there will be full training undertaken with regard to the new Policy.
I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes.
All staff need time to be able to complete such records in a more timely way.
That takes me to my final concern and that relates to the difficulty with navigation around the records . Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions . That has the potential to compromise patient management and safety .
I also enclose a copy of my report to the Secretary of State.
” 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 Choice and implementation of electronic patient-record systems are matters for individual NHS Trusts.
Verbatim wording from the response “In addition, there are a number of versions of electronic patient record and health record systems being used in many hospitals across the UK. These systems are being used to provide accurate, up-to-date, and complete information about patients at the point of care. However, the choice and implementation of these systems is a matter for individual NHS Trusts.” Source location 2015-0075-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 Individual NHS Trusts are responsible for developing and implementing patient observation policies appropriate to their patients.
Verbatim wording from the response “The Code of Practice provides a legal framework for the NHS. Individual NHS Trusts are expected to develop and implement their own patient observation policies that are appropriate to the needs of their patients and in line with this statutory guidance.” Source location 2015-0075-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 national guidance and statutory frameworks provide guidance on patient observation, with local policies expected to align with them.
Verbatim wording from the response “You ask if there is a national policy on patient engagement and observation. NHS England is planning to update its Suicide Prevention Audit Tool for Emergency Care, in light of learning from suicides in acute care settings. This stresses the importance of engagement with the patient, the recording of observations and timeliness of mental health assessment.” Source location 2015-0075-Response-by-Department-of-Health
Open published response
20 Feb 2015 Richard Jeffrey Jones · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 3 Failure to record primary responsibility for patient care during transfers of care View source Failure to share patient information accurately with other agencies involved in care View source Failure to record information obtained from mental health patients, including perceived risk and assessment urgency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Richard Jeffrey Jones · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Richard Jeffrey Jones was at home alone and, during 14 to 15 October 2012, voluntarily ingested a quantity of tramadol that led to loss of consciousness, respiratory depression and aspiration of gastric contents, causing his death. The report raised concerns about recording and sharing information on risk and urgency, and about identifying primary responsibility when care was transferred between mental health services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to record primary responsibility for patient care during transfers of care
Wider context from the report “I am concerned in particular as to the following matters :
a) As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment.
b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.
c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to share patient information accurately with other agencies involved in care
Wider context from the report “I am concerned in particular as to the following matters :
a) As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment.
b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency .
c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to record information obtained from mental health patients, including perceived risk and assessment urgency
Wider context from the report “I am concerned in particular as to the following matters :
a) As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment .
b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.
c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue discussions with the Ministry of Defence and NHS England to address concerns about information sharing and care responsibility for armed forces personnel.
Verbatim wording from the response “At a national level, the Department of Health (DH) works closely with the MoD and with NHS England to ensure that service personnel receive the right health services. Medical notes relating to an individual patient must pass readily from the MoD to the NHS and back again as appropriate. This will become increasingly important as the number of Armed Forces reservists is increased, as these personnel will access health services from the MoD when mobilised, and from the NHS at other times.” Source location 2015-0068-Response-by-Department-of-Health2
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local mental health providers are expected to address the specific case and concerns from their local perspective.
Verbatim wording from the response “Firstly, I would expect the mental health providers named in your report to provide comment on the detail of this particular case and to address your concerns from their local perspective.” Source location 2015-0068-Response-by-Department-of-Health2
Open published response
19 Feb 2015 Elizabeth Muriel Leah · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Delays in getting patients into A and E departments View source Insufficient ambulance and staff capacity for timely ambulance response View source Bed blocking throughout hospital systems View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elizabeth Muriel Leah · 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 Muriel Leah, an 87-year-old care home resident with severe dementia, fell on 2 July 2014 and broke her femur. Although an ambulance was called, staff were advised to take her to hospital by taxi because of an anticipated ambulance delay. The principal concerns were insufficient ambulance and staffing capacity, delays transferring patients into emergency departments, and hospital bed-blocking.
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 getting patients into A and E departments
Wider context from the report “On the occasion when she fell, an ambulance was called using the 999 system. On describing the circumstances, the Care Staff were told that they would get a call back from NHS within 60 minutes. They were also informed that there would be a delay of up to 6 hours for the ambulance to arrive. 50 minutes later the ambulance service called back and advised that she should be taken to hospital in a Taxi.
This meant that an 87 year old lady with severe dementia and a broken leg, was delivered to the hospital Emergency Department in a wheelchair in a Taxi.
When I questioned the Ambulance service Manager about this, she was very candid and accepted that the problem is that they do not have sufficient ambulances or staff available and that they are working “at 100%” all the time.
This problem is exacerbated by the delays in getting patients into the A and E Departments , which in turn is exacerbated by the bed blocking throughout the hospital systems.
These are not problems which can be alleviated locally, but require an urgent input and direction from Central Government.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 and staff capacity for timely ambulance response
Wider context from the report “On the occasion when she fell, an ambulance was called using the 999 system. On describing the circumstances, the Care Staff were told that they would get a call back from NHS within 60 minutes. They were also informed that there would be a delay of up to 6 hours for the ambulance to arrive . 50 minutes later the ambulance service called back and advised that she should be taken to hospital in a Taxi.
This meant that an 87 year old lady with severe dementia and a broken leg, was delivered to the hospital Emergency Department in a wheelchair in a Taxi.
When I questioned the Ambulance service Manager about this, she was very candid and accepted that the problem is that they do not have sufficient ambulances or staff available and that they are working “at 100%” all the time .
This problem is exacerbated by the delays in getting patients into the A and E Departments, which in turn is exacerbated by the bed blocking throughout the hospital systems.
These are not problems which can be alleviated locally, but require an urgent input and direction from Central Government.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Bed blocking throughout hospital systems
Wider context from the report “On the occasion when she fell, an ambulance was called using the 999 system. On describing the circumstances, the Care Staff were told that they would get a call back from NHS within 60 minutes. They were also informed that there would be a delay of up to 6 hours for the ambulance to arrive. 50 minutes later the ambulance service called back and advised that she should be taken to hospital in a Taxi.
This meant that an 87 year old lady with severe dementia and a broken leg, was delivered to the hospital Emergency Department in a wheelchair in a Taxi.
When I questioned the Ambulance service Manager about this, she was very candid and accepted that the problem is that they do not have sufficient ambulances or staff available and that they are working “at 100%” all the time.
This problem is exacerbated by the delays in getting patients into the A and E Departments, which in turn is exacerbated by the bed blocking throughout the hospital systems .
These are not problems which can be alleviated locally, but require an urgent input and direction from Central Government.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local commissioners are responsible for ensuring ambulance services receive sufficient funding for local population needs.
Verbatim wording from the response “I should stress that although NHS England maintains oversight of the day-to-day operation of the commissioning side of the NHS in England, it is for local commissioners to ensure that ambulance services receive sufficient funding according to the needs of their local populations. Individual Trusts must ensure a high quality service which includes determining the type of clinician, vehicle and equipment required to respond to calls based on the clinical needs of the patient.” Source location 2015-0064-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 Individual ambulance Trusts are responsible for determining clinicians, vehicles and equipment needed to respond according to patients’ clinical needs.
Verbatim wording from the response “I should stress that although NHS England maintains oversight of the day-to-day operation of the commissioning side of the NHS in England, it is for local commissioners to ensure that ambulance services receive sufficient funding according to the needs of their local populations. Individual Trusts must ensure a high quality service which includes determining the type of clinician, vehicle and equipment required to respond to calls based on the clinical needs of the patient.” Source location 2015-0064-Response-by-Department-of-Health
Open published response
Concerns raised 4 Failure to disseminate the Trust’s Interpreting Policy to staff View source Lack of national guidelines for interpreting and classifying antenatal CTG tracings View source Failure of the Trust’s Interpreting Policy to provide applicable guidance on obtaining informed consent View source Failure by staff to apply the Trust’s Interpreting Policy 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
infant Rahat Qayyum (otherwise known as Mohammed Rahat Yousaf) · 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
Infant Rahat Qayyum was delivered in very poor condition on 5 July 2013 after abnormalities on CTG traces were not fully recognised, and died on 19 July 2013 from hypoxic ischaemic encephalopathy due to or as a consequence of perinatal asphyxia. The concerns identified included the absence of national guidelines for interpreting antenatal CTG tracings and issues concerning the dissemination, application and applicability of the Trust’s Interpreting Policy, particularly in relation to informed consent.
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 disseminate the Trust’s Interpreting Policy to staff
Wider context from the report “2. The dissemination , application and applicability of the Trust’s Interpreting Policy, by its staff , in force at the material time (with particular regard to the obtaining of informed consent).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 guidelines for interpreting and classifying antenatal CTG tracings
Wider context from the report “1. Whilst Pennine Acute Hospitals NHS Trust has now established its own local guidelines based upon recent research conducted in Bristol, there are no national guidelines on how to interpret and/or classify antenatal (as opposed to intra-partum) CTG tracings .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Trust’s Interpreting Policy to provide applicable guidance on obtaining informed consent
Wider context from the report “2. The dissemination, application and applicability of the Trust’s Interpreting Policy , by its staff, in force at the material time (with particular regard to the obtaining of informed consent ).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 staff to apply the Trust’s Interpreting Policy
Wider context from the report “2. The dissemination, application and applicability of the Trust’s Interpreting Policy, by its staff , in force at the material time (with particular regard to the obtaining of informed consent).
” Open source report
Concerns raised 1 Failure of toilet cubicle doors to permit safe access when an occupant is slumped forward 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
Anne Horner · 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
Anne Horner was a resident at Oak Lodge Nursing Home when she sustained head injuries in two incidents involving a toilet cubicle door. Following the second incident on 25 March 2014, she was found unresponsive and died at Salford Royal Hospital from a traumatic head injury. The principal concern was that the toilet cubicle door and available clearance may not have adequately accommodated a resident who had fallen or was slumped forward.
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 toilet cubicle doors to permit safe access when an occupant is slumped forward
Wider context from the report “4. The evidence at Inquest confirmed that the bathroom facility which included the toilet cubicle was constructed in or about 1988 in compliance with the relevant Planning Permission and Building Regulations. I accept that the facility had been used on many previous occasions without incident. The fact however that a resident sustained injury on two separate occasions within a period of 6 weeks gives rise to concern. I anticipate that there are many establishments within England and Wales where toilet facilities are not dissimilar to those at Oak Lodge Nursing Home. I understand that separate guidance in relation to disabled toilet design suggests doors that open outwards to facilitate access if someone falls behind the door. Whilst photographic images produced at Inquest suggested adequate door clearance for a resident sitting normally on the toilet, that would not be so for an individual resident who sat / was slumped forward.
” Open source report
6 Feb 2015 George Allan Taylor · Prevention of Future Deaths report Cornwall
View report summary
Concerns raised 1 Lack of acute psychiatric beds View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
George Allan Taylor · 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 Allan Taylor, who had a history of mental health issues and previous overdoses, was found hanged at home on 2 July 2013 after leaving a care home and returning home under daily supervision. The report identified concerns about inadequate provision of acute psychiatric beds in Cornwall, with 8 to 12 patients per month typically sent out of county, and noted that a future death could result from this lack of beds in changed 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 Lack of acute psychiatric beds
Wider context from the report “It was established in evidence that Mr Taylor’s death was not caused by the lack of an acute psychiatric bed.
Furthermore, it was established that no patient had died out of county because an in county acute psychiatric bed was not available. It was further established that no patient had died in Cornwall while waiting for an acute psychiatric bed to become available.
That said, it appears far from desirable that 8 to 12 patients are being sent out of county per month due to a lack of acute psychiatric beds .
It is easy to see that, with only a small change in circumstances, a future death could result as a consequence of a lack of acute psychiatric beds .
” 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 Set out in the Mandate that plans must ensure people in mental health crisis are not turned away.
Verbatim wording from the response “I was saddened to hear of Mr Taylor’s death. The Government has made it clear that beds must always be available for those who need them and have set out in the Mandate — our annual contract with NHS England — that plans must be put in place to ensure no one in mental health crisis will be turned away. I have made NHS England aware of your report.” Source location 2015-0044-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 Decisions about the appropriate number of mental health beds in Cornwall are for local clinicians to make.
Verbatim wording from the response “As you heard during the inquest, the local Clinical Commissioning Group (CCG) is reviewing bed provision in Cornwall with the Cornwall Partnership Foundation Trust. Decisions about the appropriate number of beds to be commissioned in Cornwall are for local clinicians to make. I note that you have also sent your report to the CCG.” Source location 2015-0044-Response-by-Department-of-Health
Open published response
3 Feb 2015 Shannon Kimberley Gee · Prevention of Future Deaths report Cornwall
View report summary
Concerns raised 3 Difficulties in transferring medical notes and records View source Delays in resolving disputes over which organisation should treat a patient View source Failure of OSW and CMHT treatment thresholds to provide continuous service coverage 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
Shannon Kimberley Gee · 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
Shannon Kimberley Gee, aged 16, died as the result of an Accident. The report raised concerns about gaps between mental health services, delays of weeks in resolving disputes over responsibility for treatment, and difficulties transferring medical notes and records.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Difficulties in transferring medical notes and records
Wider context from the report “The situation now is improved from when ████████ encountered the delay in treatment to her but, on the evidence should ████████ a delay of ‘weeks’ in resolving clinical disputes as to which organisation should treat a patient is still worrying. Ideally, there should be a seamless union between the two organisations.
The fact that there is not appears to be a consequence of the maximum threshold for treatment by OSW being lower than the minimum threshold for acceptance on to the CMHT workload. Put another way, it is entirely conceivable that both OSW and CMHT may be correct in applying their respective rules as to whether a patient needs to be taken on where that patient’s presenting complaints falls between the two organisations’ rules. That may require formal guidance to resolve hence directing this letter to the Secretary in addition to the Commissioners. The difficulties set out concerning the transfer of medical notes and records appear more difficult to justify.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 resolving disputes over which organisation should treat a patient
Wider context from the report “The situation now is improved from when ████████ encountered the delay in treatment to her but, on the evidence should ████████ a delay of ‘weeks’ in resolving clinical disputes as to which organisation should treat a patient is still worrying . Ideally, there should be a seamless union between the two organisations.
The fact that there is not appears to be a consequence of the maximum threshold for treatment by OSW being lower than the minimum threshold for acceptance on to the CMHT workload. Put another way, it is entirely conceivable that both OSW and CMHT may be correct in applying their respective rules as to whether a patient needs to be taken on where that patient’s presenting complaints falls between the two organisations’ rules. That may require formal guidance to resolve hence directing this letter to the Secretary in addition to the Commissioners. The difficulties set out concerning the transfer of medical notes and records appear more difficult to justify.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 OSW and CMHT treatment thresholds to provide continuous service coverage
Wider context from the report “The situation now is improved from when ████████ encountered the delay in treatment to her but, on the evidence should ████████ a delay of ‘weeks’ in resolving clinical disputes as to which organisation should treat a patient is still worrying. Ideally, there should be a seamless union between the two organisations.
The fact that there is not appears to be a consequence of the maximum threshold for treatment by OSW being lower than the minimum threshold for acceptance on to the CMHT workload . Put another way, it is entirely conceivable that both OSW and CMHT may be correct in applying their respective rules as to whether a patient needs to be taken on where that patient’s presenting complaints falls between the two organisations’ rules . That may require formal guidance to resolve hence directing this letter to the Secretary in addition to the Commissioners. The difficulties set out concerning the transfer of medical notes and records appear more difficult to justify.
” Open source report
2 Feb 2015 Kimberley Lauren Lindfield · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 6 Lack of a written protocol defining increased observations and required recording View source Lack of auditing of the appropriateness and timeliness of responses to mental health assessment presentations View source Failure to assign clear responsibility for recording increased observations View source Failure to ensure nursing and clinical staff understand their record-keeping responsibilities View source Lack of written guidance for clinical review and care-plan changes in response to new risks View source Lack of periodic audits of record keeping in similar cases 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
Kimberley Lauren Lindfield · 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
Kimberley Lauren Lindfield, who had a history of mental health problems and self-harm, was admitted to hospital after taking an overdose. While on Ward A10, she was found hanging from a dressing gown cord and died several days later after suffering severe brain damage. The principal concerns were failures to arrange a timely mental health assessment, record and respond to increased self-harm observations and risk information, maintain appropriate clinical management, and ensure staff followed relevant referral policies.
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 written protocol defining increased observations and required recording
Wider context from the report “2. Whenever an increased level of observations is initiated pending a mental health assessment because of the concern about a patient’s mental state and/or self harm/suicidal behaviour there should be a clear written policy or protocol setting out what those observations actually involve (e.g. what 1 in every 15 minutes means and precisely what should be recorded) and the recording of them with a clear chain of responsibility with the obligation on one appropriate member of staff to ensure that this is done. I am concerned that at present such does not exist .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 of the appropriateness and timeliness of responses to mental health assessment presentations
Wider context from the report “1. I am told that all patients presenting with symptoms of mental illness/mental disorder and/or after reported self harm/suicidal behaviour will now be automatically referred for a mental health assessment to be conducted as soon as possible whether that referral is from A& E or any ward. Pending that assessment, mental health staff can give advice by phone concerning the patients interim care and management. Both UHSM and MHSC provided evidence about a joint understanding and approach as well as a training and induction of staff. GMW may also be involved in such a case. That was to a very large extent the assurance I was provided after the death of Mr Dean. There were no plans or thoughts to audit whether or not in practice there was an appropriate and timely response to such presentations to ensure that the new system was actually working. In view of the history I am concerned that without such an auditing process failures of care may take place as identified above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to assign clear responsibility for recording increased observations
Wider context from the report “2. Whenever an increased level of observations is initiated pending a mental health assessment because of the concern about a patient’s mental state and/or self harm/suicidal behaviour there should be a clear written policy or protocol setting out what those observations actually involve (e.g. what 1 in every 15 minutes means and precisely what should be recorded) and the recording of them with a clear chain of responsibility with the obligation on one appropriate member of staff to ensure that this is done . I am concerned that at present such does not exist .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 nursing and clinical staff understand their record-keeping responsibilities
Wider context from the report “4. I am concerned that all UHSM Nursing and Clinical staff should be reminded of their responsibilities for good quality record keeping as an essential part of patient care and that there are periodic audits of record keeping in similar cases to ensure that appropriate standards are being met.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 written guidance for clinical review and care-plan changes in response to new risks
Wider context from the report “3. I am concerned that there is currently no written protocol or guidance where there is an appropriate clinical review and there should be a change in the care and management plan in response to new or changed circumstances or new risks .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 periodic audits of record keeping in similar cases
Wider context from the report “4. I am concerned that all UHSM Nursing and Clinical staff should be reminded of their responsibilities for good quality record keeping as an essential part of patient care and that there are periodic audits of record keeping in similar cases to ensure that appropriate standards are being met .
” 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 Review and bring into effect the revised Mental Health Act Code of Practice, including guidance on enhanced patient observation.
Verbatim wording from the response “Further guidelines for patient observation are contained in the Mental Health Act 1983 Code of Practice. This has recently been reviewed by the Department of Health and the revised edition came into effect on 1st April 2015. Within this code is a section which advises on enhanced observation for patients in hospital wards and services.” Source location 2015-0036-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a self-harm indicator in the Public Health Outcomes Framework measuring emergency-department attendances and psychosocial assessments.
Verbatim wording from the response “In the Department’s current Public Health Outcomes Framework a new self-harm indicator was introduced; this measures:” Source location 2015-0036-Response-by-Department-of-Health
Open published response
29 Jan 2015 Brian Marks · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of reliable visual differentiation between PEJ and PEG tubes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brian Marks · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Brian Marks had motor neurone disease and, in the last stages of life in hospital, was being fed and given medication via a PEJ tube after aspirating and contracting pneumonia. A nurse mistook the PEJ tube for a PEG tube, and the report identified that the similar appearance of the tubes could lead to confusion and that they should be differentiated using colour coding.
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 reliable visual differentiation between PEJ and PEG tubes
Wider context from the report “The appearance of the PEJ tube and the PEG tube are very similar and could be easily confused the one with the other. In discussion with the witnesses, including the lead dietician, it was agreed that a simple colour coding system could be implemented so that even when in situ, the tubes would be immediately able to be differentiated .
” 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 Further colour coding may not reliably prevent tube confusion and could introduce additional hazards, including misconnections and risks for colour-blind users.
Verbatim wording from the response “Both organisations agree that feeding tubes look very similar and can therefore be confused with one another, potentially putting the patient at risk. However, the solution might not be as straightforward as it first appears.” Source location 2015-0025-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 Manufacturers cannot be compelled to change device designs unless changes form part of internationally required standards.
Verbatim wording from the response “Your suggestion of introducing a colour coding scheme has already been considered. Some experts in the field believe a suitable scheme could be helpful, although influencing manufacturers to change design to ensure easier visual distinction of their product is not always straightforward. Manufacturers cannot be compelled to make such changes where these are not part of internationally required design standards.” Source location 2015-0025-Response-by-Department-of-Health
Open published response
14 Jan 2015 Max Carlton-Smith · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 9 Failure to provide on-site medical assistance at unlicensed raves View source Insufficient police resources to close down illegal rave venues View source Barricading of rave venues against police and other emergency access View source Failure to regulate fire exits at rave venues View source Failure to regulate fire safety procedures at rave venues View source Delays in calling ambulance services after a medical collapse View source Lack of police power to enter squatted commercial premises to prevent illegal raves View source Lack of police power to enter squatted commercial premises to prevent illegal raves View source Inadequate ventilation for very hot rave venues View source See 6 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
Max Carlton-Smith · 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
Max Carlton-Smith died after taking MDMA at an illegal rave and collapsing when emergency medical assistance was not summoned immediately. The rave had no on-site medical assistance, inadequate ventilation, and unregulated fire exits and procedures; the report also raised concerns about delays in calling an ambulance and the authorities’ ability to intervene at the squatted commercial premises.
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 on-site medical assistance at unlicensed raves
Wider context from the report “The organizers of the unlicensed rave had not provided on-site medical assistance and had spent between 12 and 42 minutes before calling the ambulance service, when the deceased collapsed. There was inadequate ventilation for a very hot venue, and fire exits and procedure had not been regulated. The organizers had taken over an empty squatted commercial building and barricaded against those who attempted to enter, (including police, who attended and spoke earlier to a security man and then later following complaints of noise). I concluded that had the event been licensed and normal facilities and regulation in place, he would probably not have died when he did.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 police resources to close down illegal rave venues
Wider context from the report “Police evidence was that they had no power to enter (nor had the ambulance service) a commercial premises (as opposed to private premises) that had been squatted unless a crime had been committed or in an emergency. There were not resources available on this weekend to close down the venue when the rave was taking place, without diverting all the officers in the borough force . It was reported that the MPS now has disseminated to boroughs notice of a facility to access officers from other areas and that the borough police were more likely to intervene in the future. In the event it was reported that 21 officers attended but people left and evaded statements or gave false contact details, so that none of the organizers or staff have been traced.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Barricading of rave venues against police and other emergency access
Wider context from the report “The organizers of the unlicensed rave had not provided on-site medical assistance and had spent between 12 and 42 minutes before calling the ambulance service, when the deceased collapsed. There was inadequate ventilation for a very hot venue, and fire exits and procedure had not been regulated. The organizers had taken over an empty squatted commercial building and barricaded against those who attempted to enter , (including police , who attended and spoke earlier to a security man and then later following complaints of noise). I concluded that had the event been licensed and normal facilities and regulation in place, he would probably not have died when he did.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 regulate fire exits at rave venues
Wider context from the report “The organizers of the unlicensed rave had not provided on-site medical assistance and had spent between 12 and 42 minutes before calling the ambulance service, when the deceased collapsed. There was inadequate ventilation for a very hot venue, and fire exits and procedure had not been regulated. The organizers had taken over an empty squatted commercial building and barricaded against those who attempted to enter, (including police, who attended and spoke earlier to a security man and then later following complaints of noise). I concluded that had the event been licensed and normal facilities and regulation in place, he would probably not have died when he did.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 regulate fire safety procedures at rave venues
Wider context from the report “The organizers of the unlicensed rave had not provided on-site medical assistance and had spent between 12 and 42 minutes before calling the ambulance service, when the deceased collapsed. There was inadequate ventilation for a very hot venue, and fire exits and procedure had not been regulated . The organizers had taken over an empty squatted commercial building and barricaded against those who attempted to enter, (including police, who attended and spoke earlier to a security man and then later following complaints of noise). I concluded that had the event been licensed and normal facilities and regulation in place, he would probably not have died when he did.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 calling ambulance services after a medical collapse
Wider context from the report “The organizers of the unlicensed rave had not provided on-site medical assistance and had spent between 12 and 42 minutes before calling the ambulance service , when the deceased collapsed. There was inadequate ventilation for a very hot venue, and fire exits and procedure had not been regulated. The organizers had taken over an empty squatted commercial building and barricaded against those who attempted to enter, (including police, who attended and spoke earlier to a security man and then later following complaints of noise). I concluded that had the event been licensed and normal facilities and regulation in place, he would probably not have died when he did.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 police power to enter squatted commercial premises to prevent illegal raves
Wider context from the report “DS Howell specifically recommended that this report be written as the police would like the power to enter squatted commercial premises , to prevent an illegal rave being held , which was more efficient and effective than trying to intervene when it was in operation. Given the increased risks of death associated with unlicensed raves, these proposals would seem to prevent future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of police power to enter squatted commercial premises to prevent illegal raves
Wider context from the report “Police evidence was that they had no power to enter (nor had the ambulance service) a commercial premises (as opposed to private premises) that had been squatted unless a crime had been committed or in an emergency. There were not resources available on this weekend to close down the venue when the rave was taking place, without diverting all the officers in the borough force. It was reported that the MPS now has disseminated to boroughs notice of a facility to access officers from other areas and that the borough police were more likely to intervene in the future. In the event it was reported that 21 officers attended but people left and evaded statements or gave false contact details, so that none of the organizers or staff have been traced.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 ventilation for very hot rave venues
Wider context from the report “The organizers of the unlicensed rave had not provided on-site medical assistance and had spent between 12 and 42 minutes before calling the ambulance service, when the deceased collapsed. There was inadequate ventilation for a very hot venue , and fire exits and procedure had not been regulated. The organizers had taken over an empty squatted commercial building and barricaded against those who attempted to enter, (including police, who attended and spoke earlier to a security man and then later following complaints of noise). I concluded that had the event been licensed and normal facilities and regulation in place, he would probably not have died when he did.
” Open source report
9 Jan 2015 Annette Charlton · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Almost identical medication boxes 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
Annette Charlton · 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
Annette Charlton, who had emphysema and lung fibrosis requiring continuous oxygen therapy, was dispensed Naproxen instead of prescribed antibiotics and died on 28 September 2014. The principal concern was that medication manufacturers used almost identical packaging, which was considered likely to contribute to dispensing errors and potentially patient deaths.
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 Almost identical medication boxes
Wider context from the report “(1) Manufacturers are able to produce medication in almost identical boxes which is very likely to contribute to dispensing errors and potentially patient deaths.
” Open source report
9 Jan 2015 Pauline Taylor · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 2 Lack of a designated clinical case manager for complex and uncertain cases View source Insufficient precision of the surgical term ‘nephroureterectomy’ View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Pauline Taylor · 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
Pauline Taylor underwent surgery in November 2010 intended to remove her right kidney and ureter, but only approximately 5 cm of the ureter was removed. Persistent pain led to the discovery of an inoperable tumour in the remaining ureter, followed by metastases in the liver and lungs; she died at home on 12 May 2012. Concerns included ambiguity in the term “nephroureterectomy” and the absence of a designated person to coordinate care in this complex case.
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 designated clinical case manager for complex and uncertain cases
Wider context from the report “(2) In this complex case, no firm diagnosis had been established. There was no one person in the clinical team whose role was to monitor progress, liaise with the patient and the various clinicians involved and ensure her significant ongoing problems were heard and heeded. Evidence was taken at the Inquest from an expert witness who described the benefits of a ‘case manager’ role, used in other NHS Trusts in cases characterised by uncertainty and complexity.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 precision of the surgical term ‘nephroureterectomy’
Wider context from the report “(1) The surgical term ‘nephroureterectomy’ appears to lack sufficient precision to avoid any possibility of misunderstandings between clinicians as to the extent of the procedure to be performed. One surgeon gave evidence at the Inquest that the term involved the removal of a kidney and the entire ureter. Another surgeon, however, gave evidence that the term was sufficiently broad to allow the removal of only a portion of the ureter. By the time the difference in their understanding of this term of art became clear the deceased had an inoperable tumour located in the remaining portion of the ureter.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The local Trust is responsible for addressing whether a clinical case manager role is needed in this case.
Verbatim wording from the response “Decisions on how each clinical team operates and the specific roles within teams are issues for the employing Trust. Decisions need to be taken based on the relative skill mix and experience of the clinicians involved, as well as the complexity and seriousness of the cases handled. Your concern about the lack of a clinical “case manager” in this particular case is a matter for the local Trust to address.” Source location 2015-0008-Response-by-Department-of-Health
Open published response
Concerns raised 1 Insufficient observation levels for patients in seclusion under the current policy View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dale Owen Ricardo Scott Proverbs · 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
Dale Owen Ricardo Scott Proverbs, a patient detained under the Mental Health Act and placed in seclusion at North London Clinic, collapsed after continuous observation was not maintained and died. The report identified concerns that Partnerships In Care’s observation policies were not followed and that the applicable level of observation could be insufficient to prevent another fatality in similar 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 observation levels for patients in seclusion under the current policy
Wider context from the report “That there were, at the time of Mr Proverbs death, Partnership In Care Policies in place that created a higher standard of observation required for patients on seclusion than the Code of Practice for The Mental Heath Act 1983 prescribed.
The Partnerships In Care Policies in place at the time of Mr Proverb’s death, if followed, are likely to have prevented his death.
If the Code of Practice for the Mental Heath Act 1983 were to be followed by Partnerships In Care, which is now their policy, then the level of observation for patients in seclusion would not be enough to prevent another fatality were the circumstances to be the same as those surrounding Mr Proverbs death.
” 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 Constant observation is not always appropriate because it may be unnecessarily restrictive; the Code therefore retains its existing overall observation requirement.
Verbatim wording from the response “Your main concern is however that the levels of observation recommended in the MHA Code of Practice for patients in seclusion are not sufficient enough to prevent a death from occurring in similar circumstances.” Source location 2015-0010-Response-by-Department-of-Health
Open published response
Concerns raised 1 Lack of guidance for GPs when patients are not collecting medication required to treat their mental health conditions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Ioannou · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 4 April 2014, John Ioannou fatally injured himself after jumping from a window at his home. The report identified a concern that there was no guidance for GPs when a patient was not collecting medication required to treat a mental health condition, and that this information was not available to the Mental Health Team.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for GPs when patients are not collecting medication required to treat their mental health conditions
Wider context from the report “There was no guidance for GPs where the patient is not collecting medication required to treat their mental health condition (s).
” 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 NICE guidance addresses poor adherence by requiring re-referral to secondary care and development of shared risk management plans.
Verbatim wording from the response “The National Institute for Health and Clinical Excellence (NICE) has published guidelines which set out best practice for the treatment of Bipolar Disorder. This includes guidance that where a patient is being treated solely in a primary care setting (e.g. by a GP) the patient should be re-referred to secondary care if treatment adherence is poor. The guidelines also state that in managing crisis, risk and challenging behaviour in adults with Bipolar Disorder secondary care providers should develop a risk management plan and share it with the patient’s GP.” Source location 2015-0012-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 Monitoring whether patients collect or take medication would be difficult because of scale, data-sharing, consent and treatment-refusal constraints.
Verbatim wording from the response “However, there is a larger question of how a GP would become aware that a patient had stopped taking medication, particularly if medication is prescribed on a repeat prescription which allows patients to order re-fills without seeing their GPs. Over one billion prescription items are issued by general practices each year and it would therefore be a large and complex task to monitor individual patients. Aside from the practicalities, there would be issues of appropriate data sharing, patient consent, and the right to refuse treatment. NHS England advises that it has sought the advice of its Primary Care Patient Safety Expert Group and Mental Health Patient Safety Expert Group on what action might feasibly be taken in this area. NHS England will be able to provide an update on these discussions by the end of April 2015.” Source location 2015-0012-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 NHS England is responsible for considering feasible action on monitoring medication non-collection and providing an update.
Verbatim wording from the response “However, there is a larger question of how a GP would become aware that a patient had stopped taking medication, particularly if medication is prescribed on a repeat prescription which allows patients to order re-fills without seeing their GPs. Over one billion prescription items are issued by general practices each year and it would therefore be a large and complex task to monitor individual patients. Aside from the practicalities, there would be issues of appropriate data sharing, patient consent, and the right to refuse treatment. NHS England advises that it has sought the advice of its Primary Care Patient Safety Expert Group and Mental Health Patient Safety Expert Group on what action might feasibly be taken in this area. NHS England will be able to provide an update on these discussions by the end of April 2015.” Source location 2015-0012-Response-by-Department-of-Health
Open published response
Concerns raised 2 Failure to consider NICE guidance on late onset sepsis in babies under 1500 g View source Lack of research into HeRO or other infection monitoring systems View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Carla London · 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
Carla London was born extremely premature and died in hospital on 26 April 2011 after rapidly deteriorating following treatment for suspected sepsis. The report raised concerns about the need for NICE guidance on late-onset sepsis in babies weighing under 1500 g and research into HeRO or other infection-monitoring systems.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to consider NICE guidance on late onset sepsis in babies under 1500 g
Wider context from the report “That coroner shares the concerns expressed by the independent expert that consideration should be given to NICE guidance on late onset sepsis in under 1500 gms babies and that and for research in to HeRO or other infection monitoring systems.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of research into HeRO or other infection monitoring systems
Wider context from the report “That coroner shares the concerns expressed by the independent expert that consideration should be given to NICE guidance on late onset sepsis in under 1500 gms babies and that and for research in to HeRO or other infection monitoring systems .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local maternity and neonatal providers determine how services are delivered in their areas, having regard to NICE guidance.
Verbatim wording from the response “Local maternity and neonatal care providers determine how best to deliver services in their area. In doing so we would always expect them to give due regard to NICE guidance.” Source location 2015-0003-Response-by-Department-of-Health
Open published response
19 Dec 2014 Ms Pauline Verona Edwards · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 2 Failure to provide appropriate supervision for EU-trained doctors View source Inability to ensure equivalence of EU-trained doctors’ qualifications, training and experience View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Ms Pauline Verona Edwards · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ms Pauline Verona Edwards, a healthy 49-year-old woman, died at St Georges Hospital on 15 December 2010 after developing laryngospasm, hypoxia, cardiac arrest and irreversible brain damage following surgery for an ovarian cyst. The report identified concerns that EU-trained doctors’ qualifications could be accepted without equivalent training and experience, and that hospitals might consequently allow such doctors to practise unsupervised, increasing risks to patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate supervision for EU-trained doctors
Wider context from the report “(1) That UK Hospitals are forced by EU law to accept the qualifications of EU trained doctors even though such doctors may not have the same training and experience as an equivalently graded doctor in the UK
(2) That UK Hospitals are unaware of this and thus allow such doctors to practice unsupervised and thus put patients’ lives at increased 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 Inability to ensure equivalence of EU-trained doctors’ qualifications, training and experience
Wider context from the report “(1) That UK Hospitals are forced by EU law to accept the qualifications of EU trained doctors even though such doctors may not have the same training and experience as an equivalently graded doctor in the UK
(2) That UK Hospitals are unaware of this and thus allow such doctors to practice unsupervised and thus put patients’ lives at increased risk.
” Open source report
17 Dec 2014 Rebecca Louise Overy · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 2 Lack of secure mental health care provision for young adults aged 18-24 with a similar clinical picture View source Failure to ensure that immediate transfers at age 18 are in the person's best interests View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rebecca Louise Overy · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Rebecca Louise Overy died from hypoxic brain injury caused by asphyxia while in adult secure mental health detention. Her fatal injury was self-inflicted after she was transferred from child and adolescent secure mental health detention to an adult admission ward the day after her 18th birthday, without a gradual transition plan; concerns included the immediate transfer and the lack of secure mental health care for young adults aged 18–24 with a similar clinical picture.
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 secure mental health care provision for young adults aged 18-24 with a similar clinical picture
Wider context from the report “2. That there is no provision for secure mental health care for young adults in the age range 18-24, with a clinical picture similar to Rebecca’s .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that immediate transfers at age 18 are in the person's best interests
Wider context from the report “1. That the immediate transfer of Miss Overy the day after her 18th birthday was not in her best interests , was detrimental to her mental health and occurred purely due to the operation of s 30 of the Health and Social Care Act, whereby the commissioners were obliged to arrange an immediate transfer, and the clinicians to concur with it , lest they be in breach of the act.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing adult wards and transition guidance are considered capable of meeting the clinical and transition needs of young adults aged 18 to 24.
Verbatim wording from the response “You were concerned that there is no provision for secure mental health care for young adults aged 18–24 with a similar clinical picture. Whilst there are no dedicated wards for 18 to 24 year olds, there are wards that meet the clinical needs of patients with the same and similar presentation to Miss Overy. There is transition guidance in place which advises that arrangements are made within adult wards to ensure that appropriate patient needs, as highlighted in clinical assessments, are met. Receiving providers should make appropriate plans and extend the services available to aid the transition arrangements for young adults.” Source location 2014-0535R
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The cited legislation is not known to require immediate transfer, preventing comment on that specific issue pending clarification.
Verbatim wording from the response “You refer to the “operation of a section 30 of the Health and Social Care Act, whereby the commissioners were obliged to arrange an immediate transfer”. I am not aware of a provision from either the Health and Social Care Act or the Mental Health Act which stipulates this, so am unable to comment on this specific matter. However, if you are able to provide clarification for this reference I am happy to respond further on this point.” Source location 2014-0535R
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The transfer was planned for months, clinically assessed as appropriate, and could not safely be delayed or replaced by community discharge.
Verbatim wording from the response “NHS England have assured me that Miss Overy’s future care had been considered for many months prior to her transfer including the appropriate type of environment and level of security required. They have confirmed that an independent clinical access assessment had been undertaken that identified that Miss Overy should be in an adult low secure placement when she turned 18. The CAMHS placement where she was, was not of a low secure environmental or therapeutic standard that would meet her identified needs. In addition, Miss Overy’s significant levels of risk and patterns of behaviour meant that she would not have been able either to remain within a CAMHS or be discharged to the community when she became an adult.” Source location 2014-0535R
Open published response
16 Dec 2014 Janette Insley · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Failure to provide inpatient access to suitably qualified psychological practitioners and referral resources View source Undue emphasis on community-based psychological therapy to the detriment of inpatient services View source Delays in community-based psychological therapy referrals after discharge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Janette Insley · 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
Janette Insley had a longstanding history of depressive illness and was admitted to a mental health unit after her mental and psychological health deteriorated. After failing to return from home leave on 3 August 2014, she was found deceased at home having self-ligatured; concerns included a lack of inpatient psychological therapy provision and delays in accessing community-based therapy after discharge.
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 inpatient access to suitably qualified psychological practitioners and referral resources
Wider context from the report “1. During the course of the evidence I was told that whilst the Consultant Psychiatrist considered that a referral to a Psychologist was the most appropriate course of treatment available, staff were unable to make any such referral for inpatients due to lack of i) availability of suitably qualified practitioners and ii) resources . There is therefore a clear service gap.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Undue emphasis on community-based psychological therapy to the detriment of inpatient services
Wider context from the report “2. I was also told that most, if not all, Psychological therapy now takes place within the community . It would appear that undue emphasis is currently being placed upon this setting of care, to the detriment of inpatient services .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in community-based psychological therapy referrals after discharge
Wider context from the report “3. That any referral to/consultation with a Psychologist based within the community would have taken at least 3-4 weeks post-discharge , thus leaving the patient without therapy during a particularly vulnerable period .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a five-year mental health plan setting out actions to improve access and waiting times for mental health services.
Verbatim wording from the response “The Outcomes Framework for the NHS in England clearly states that the NHS should carry on expanding access to psychological services as part of the IAPT programme. In addition, the Department’s new five-year plan for mental health, Achieving Better Access to Mental Health Services by 2020 was published in October 2014. This articulates our ambition and the immediate actions we will take this year and next to achieve better access and waiting times in mental health services. This includes the IAPT commitment of treatment within 6 weeks for 75% of people with 95% of people being treated within 18 weeks.” Source location 2014-0574-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Take immediate actions to improve mental health access and waiting times, including IAPT treatment within six weeks for 75% and within 18 weeks for 95% of people.
Verbatim wording from the response “The Outcomes Framework for the NHS in England clearly states that the NHS should carry on expanding access to psychological services as part of the IAPT programme. In addition, the Department’s new five-year plan for mental health, Achieving Better Access to Mental Health Services by 2020 was published in October 2014. This articulates our ambition and the immediate actions we will take this year and next to achieve better access and waiting times in mental health services. This includes the IAPT commitment of treatment within 6 weeks for 75% of people with 95% of people being treated within 18 weeks.” Source location 2014-0574-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The NHS Trust and Clinical Commissioning Group are responsible for addressing the concerns about local psychological therapy provision.
Verbatim wording from the response “You have copied your report to the relevant NHS Trust and Clinical Commissioning Group. The issues you raised are most appropriately addressed at a local level and I would expect the NHS organisations responsible to respond fully to your concerns.” Source location 2014-0574-Response-by-Department-of-Health
Open published response
Concerns raised 6 Lack of a set policy for when to call an ambulance View source Failure to properly check returned specialist investigation results View source Unclear and high threshold for recognising a medical emergency View source Failure to ensure necessary specialist investigations are recorded and carried out View source Inadequate training and clarity for night-time staff assessing medical emergencies View source Failure to consistently record and flag key healthcare events between daytime and night-time staff View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
GARRY GILBEY · 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
Garry Gilbey developed worsening arm, chest and breathing symptoms while imprisoned and was later diagnosed with inoperable lung cancer after being admitted to hospital on 25 June 2012. He died on 3 July 2012. The substantive concerns included unclear ambulance-call procedures and emergency thresholds for prison officers, inadequate communication of healthcare events to night staff, and failures to ensure that specialist investigations were arranged, completed and properly checked.
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 set policy for when to call an ambulance
Wider context from the report “1. The Prison did not have a set policy about when an ambulance should be called. This was left to the judgement of the prison officer(s) making an assessment of the prisoner from outside the cell and whether what they observed amounted to a medical emergency. In addition, it was not clear what amounted to a medical emergency and that the threshold was high. This raises genuine concern in relation to those prisoners who do not have 24/7 medically trained staff available to make emergency assessments of prisoners during the night.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 properly check returned specialist investigation results
Wider context from the report “4. There were also worrying aspects to prison health care systems including checking that all necessary specialist investigations are fully recorded and carried out as well as results properly checked when they return .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 and high threshold for recognising a medical emergency
Wider context from the report “1. The Prison did not have a set policy about when an ambulance should be called. This was left to the judgement of the prison officer(s) making an assessment of the prisoner from outside the cell and whether what they observed amounted to a medical emergency. In addition, it was not clear what amounted to a medical emergency and that the threshold was high. This raises genuine concern in relation to those prisoners who do not have 24/7 medically trained staff available to make emergency assessments of prisoners during the night.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 necessary specialist investigations are recorded and carried out
Wider context from the report “4. There were also worrying aspects to prison health care systems including checking that all necessary specialist investigations are fully recorded and carried out as well as results properly checked when they return.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 training and clarity for night-time staff assessing medical emergencies
Wider context from the report “2. In turn this raises concern about the adequacy of training and clarity of what amounts to a medical emergency for those night time prison staff involved in having to make dynamic risk assessment especially for those prisoners who are at higher risk of a chronic condition developing into an acute episode e.g. during the referral period to a hospital especially when a very serious underlying condition is suspected such as lung cancer that has the capacity to affect breathing suddenly even though a prisoner may initially appear to be able to speak.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to consistently record and flag key healthcare events between daytime and night-time staff
Wider context from the report “3. There was no clear or consistent system to flag key healthcare events during the day and there seemed to be a variable practice/policy in place that not all healthcare staff seemed to be familiar with or followed so that less relevant information was recorded such as an additional pillown being supplied yet important information such as nebuliser treatment or having a low threshold for medical review if symptoms reoccur or worsen was not consistently recorded in a way that would enable daytime medical staff to flag prisoner healthcare concerns to night-time prison staff.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue national guidance requiring ambulance calls and immediate ambulance access protocols for prisoners in life-threatening emergencies.
Verbatim wording from the response “Healthcare contracts for prisons are performance managed by NHS England’s Area Teams at a local level, who have not alerted DH Offender Health or the NHS England Health and Justice central team to any particular problems. Guidance was issued by DH and NOMS in 2011 (“Emergency access to establishments for ambulance services”) to all prisons in England, NHS commissioners and NHS ambulance trusts. This sets out when an ambulance should be called to take a prisoner to hospital in life-threatening circumstances. The guidance covers day and night emergencies and makes the following main points:” Source location 2014-0533-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing emergency-access guidance applies during emergencies outside normal healthcare-centre hours, so 24-hour medical cover is not necessarily required.
Verbatim wording from the response “Healthcare contracts for prisons are performance managed by NHS England’s Area Teams at a local level, who have not alerted DH Offender Health or the NHS England Health and Justice central team to any particular problems. Guidance was issued by DH and NOMS in 2011 (“Emergency access to establishments for ambulance services”) to all prisons in England, NHS commissioners and NHS ambulance trusts. This sets out when an ambulance should be called to take a prisoner to hospital in life-threatening circumstances. The guidance covers day and night emergencies and makes the following main points:” Source location 2014-0533-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing professional guidance requires accurate clinical records and sharing relevant information with colleagues, addressing handover and communication concerns.
Verbatim wording from the response “The bodies regulating medical professionals have published comprehensive guidance for clinicians within the prison service, including communicating with non-clinical prison staff.” Source location 2014-0533-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The prison Governor or Director is responsible for ensuring each prison has an ambulance-access protocol.
Verbatim wording from the response “• It is the responsibility of the Governing Governor/Director to ensure that a protocol exists at each prison (regardless of security status) to facilitate immediate access for the ambulance service to both the prison and the individual prisoner when required.” Source location 2014-0533-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Ministry of Justice and National Offender Management Service can address training for non-medical prison staff.
Verbatim wording from the response “You were also concerned about the adequacy of training for night time prison staff and the handover of medical information between day/night staff. I am aware that you have also sent a copy of your report to the Ministry of Justice, which oversees the National Offender Management Service (NOMS), which will be able to address prison-related issues such as training for non-medical prison staff.” Source location 2014-0533-Response-by-Department-of-Health
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations