Concerns raised 6 Failure to remove removable bathroom rails except when required View source Failure to disseminate GRIST assessment information to staff View source Failure to rigorously complete GRIST assessments View source Failure to keep ligature-capable cords centrally so that patients cannot directly access them View source Failure to maintain an overall view of escalating patient risk View source Insufficient searching of patients’ property for concealed dangerous items 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
James Edward Boylan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Edward Boylan, who had a history of anxiety and was admitted to a mental health unit, died by hanging using a phone charger cord and a bathroom rail. The concerns included removable bathroom rails creating a ligature point, insufficient searching of patients’ property, access to a cord, and failures in recognising and communicating the escalation of his condition.
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 remove removable bathroom rails except when required
Wider context from the report “(1) Removable rails in a bathroom designed for use by disabled people had been left inadvertently ever since the unit was opened. No one seemed to be aware that these rails were removable and certainly nobody had removed them. This provided a ligature point which would otherwise have been absent in a unit which was specifically designed to have as few ligature points as possible. The Coroner is concerned that this same situation may apply in other units and people need to be aware that ligature points in mental health units should be limited as far as humanly possible, and specifically that removable rails should be removed except when actually required .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 GRIST assessment information to staff
Wider context from the report “(4) GRIST: Assessments should be more rigorously completed and disseminated so that staff are aware of their contents , because in relation to Mr Boylan this did not appear to have taken place so that an opportunity for communication of information was lost .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 rigorously complete GRIST assessments
Wider context from the report “(4) GRIST: Assessments should be more rigorously completed and disseminated so that staff are aware of their contents, because in relation to Mr Boylan this did not appear to have taken place so that an opportunity for communication of information was lost.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 keep ligature-capable cords centrally so that patients cannot directly access them
Wider context from the report “(2) Mr Boylan appears to have brought onto the ward a stanley knife blade. This was not discovered for several days. Mr Boylan only left the unit on one occasion and so could only have brought the blade onto the unit either 7 days before his death or 3 days before his death. The Coroner asks that thought be given to more robust searching of patients’ property. The origin of the cord which Mr Boylan used is not clear. It may have been his own, but the policy of having these kept centrally so that patients do not have access direct to them was not adhered to on this occasion , and so again Mr Boylan had access to something which he could use to hang himself with .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an overall view of escalating patient risk
Wider context from the report “(3) There were numerous events over the 7 days during which Mr Boylan was present on the ward for someone with an overall view to realise that his condition was escalating and that he might become a danger to himself, but because no one person had such knowledge of all the facts, this was not recognised . It is suggested that communication be improved in any way in which the Trust thinks possible.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 searching of patients’ property for concealed dangerous items
Wider context from the report “(2) Mr Boylan appears to have brought onto the ward a stanley knife blade. This was not discovered for several days. Mr Boylan only left the unit on one occasion and so could only have brought the blade onto the unit either 7 days before his death or 3 days before his death. The Coroner asks that thought be given to more robust searching of patients’ property. The origin of the cord which Mr Boylan used is not clear. It may have been his own, but the policy of having these kept centrally so that patients do not have access direct to them was not adhered to on this occasion, and so again Mr Boylan had access to something which he could use to hang himself with.
” 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 Cumbria Partnership NHS Foundation Trust is responsible for addressing the four concerns relating to events on the Dova Unit.
Verbatim wording from the response “I note that you have also addressed your report to the Cumbria Partnership NHS Foundation Trust and I would expect them to properly address the four concerns relating to events during Mr Boylan’s time on the Dova Unit at Furness General Hospital.” Source location 2014-0253-Response-by-Department-of-Health
Open published response
5 Jun 2014 Archie Hames · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Failure to ensure the integrity of tracheostomy tube attachments when using Velcro straps View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Archie Hames · 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
Three-year-old Archie Hames, who had CHARGE syndrome and relied on a tracheostomy, was found unresponsive at home on 15 January 2012 after the tracheostomy tube had become displaced. He was resuscitated and taken to hospital, but died of cerebral hypoxia on 19 January 2012; testing indicated that the attaching Velcro strap had worn the tube’s silicone eyelet, contributing to detachment and airway obstruction.
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 the integrity of tracheostomy tube attachments when using Velcro straps
Wider context from the report “• Independent expert testing of the tracheostomy tube (model AMFNF-49) manufactured by Arcadia Medical and its attaching Velcro strap (model Trachi-Hold mini, TR ACC) manufactured by Kapitex Healthcare, confirmed that their combined use compromised the integrity of the silicone eyelet to the tracheostomy tube and was more likely than not to have caused the detachment of Archie’s tube
• The further implications of such continued use
• The implications of using Velcro strap attachments with other like tracheostomy tubes.
I would ask that you consider give further consideration to the appropriateness of using Velcro strap attachments with tracheostomy tubes.
” 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 Initiate discussions with partner agencies to agree wider quality improvements reducing tracheostomy dislodgement risks, including methods of securing devices.
Verbatim wording from the response “NHS England therefore propose initiating discussions with partner agencies including NCEPOD and Patient Safety Expert Groups (PSEGs) to agree how all parties can take forward wider quality improvements to reduce the risk of tracheostomy dislodgment, including, but not limited to, the best methods of securing these devices. We would be happy to keep you updated with progress as this work goes forward.” Source location 2014-0259-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 A ban on Velcro tracheostomy holders was not considered appropriate because either fastening system may create risks and unintended harms.
Verbatim wording from the response “NHS England has considered whether it is safe and realistic to ban the use of Velcro to secure tracheostomies. A wider review of NRLS data and clinical practice suggests there are risks as well as benefits in using either fastening system, and that a ban on Velcro might introduce new unintended risks. It might also not be considered acceptable by some patients and carers.” Source location 2014-0259-Response-by-Department-of-Health
Open published response
Concerns raised 1 Insufficient ambulance availability for Red 1 and Red 2 calls View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Liam Martin Coleman · 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
Liam Martin Coleman collapsed at home in the early hours of 3 October 2012 and died after London Ambulance Service crews provided advanced life support. The principal concern was that insufficient ambulances were available to cover Red 1 and Red 2 calls during that period; the report states that the delay did not more than minimally or trivially contribute to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient ambulance availability for Red 1 and Red 2 calls
Wider context from the report “That there were insufficient ambulances available to cover the number of Red 1 and Red 2 calls in the early hours of the morning of the 3rd October 2012.
” Open source report
Concerns raised 3 Lack of a Mother and Baby Perinatal Mental Health inpatient unit in the Liverpool City Region View source Lack of a Specialist Community Perinatal Mental Health Service in the Wirral View source Sub-optimal treatment for perinatal mental health issues View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samarjit Natasha SINGH · 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
Samarjit Natasha Singh developed postnatal depression after giving birth to her son and had acts of deliberate self-harm and a threat of self-harm. On 4 December 2012, she was found in cardiac arrest following hanging and sustained an irreversible hypoxic brain injury; she died the following day. The report identified concerns about the absence of a Specialist Community Perinatal Mental Health Service and a Mother and Baby Perinatal Mental Health inpatient unit in the Liverpool City Region.
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 Mother and Baby Perinatal Mental Health inpatient unit in the Liverpool City Region
Wider context from the report “Mrs Singh suffered from severe postnatal depression following the birth of her son. Clearly she needed to be with her son whilst she was being treated for her perinatal mental health issues, given his needs.
1. There was no Specialist Community Perinatal Mental Health Service in the Wirral to meet both her son’s and her needs. The treatment that was available was sub-optimal.
2. There is not a Mother and Baby Perinatal Mental health—in-patient Unit in the Liverpool City Region serving the needs of Lancashire, Merseyside and East Cheshire . 50% of referrals from this area to the Manchester Unit decline because it is too far from family and support networks but more relevantly from older sibling children who remain in the family home
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Specialist Community Perinatal Mental Health Service in the Wirral
Wider context from the report “Mrs Singh suffered from severe postnatal depression following the birth of her son. Clearly she needed to be with her son whilst she was being treated for her perinatal mental health issues, given his needs.
1. There was no Specialist Community Perinatal Mental Health Service in the Wirral to meet both her son’s and her needs . The treatment that was available was sub-optimal.
2. There is not a Mother and Baby Perinatal Mental health—in-patient Unit in the Liverpool City Region serving the needs of Lancashire, Merseyside and East Cheshire. 50% of referrals from this area to the Manchester Unit decline because it is too far from family and support networks but more relevantly from older sibling children who remain in the family home
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Sub-optimal treatment for perinatal mental health issues
Wider context from the report “Mrs Singh suffered from severe postnatal depression following the birth of her son. Clearly she needed to be with her son whilst she was being treated for her perinatal mental health issues, given his needs.
1. There was no Specialist Community Perinatal Mental Health Service in the Wirral to meet both her son’s and her needs. The treatment that was available was sub-optimal .
2. There is not a Mother and Baby Perinatal Mental health—in-patient Unit in the Liverpool City Region serving the needs of Lancashire, Merseyside and East Cheshire. 50% of referrals from this area to the Manchester Unit decline because it is too far from family and support networks but more relevantly from older sibling children who remain in the family home
” 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 and nationally consult on a specification for specialised perinatal mental health services.
Verbatim wording from the response “NHS England has had responsibility for commissioning the ‘Specialised’ element of this pathway (Mother and Baby in-patient Units) since April 2013. A specification for these specialised perinatal services was developed by the NHS England specialised perinatal Clinical Reference Group, which comprises representatives from across the country with both clinical members and patients/Carers. The specification was subject to national consultation and NHS England work with the Royal College to develop quality standards.” Source location 2014-0239-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 Work with the Royal College to develop quality standards for specialised perinatal mental health services.
Verbatim wording from the response “NHS England has had responsibility for commissioning the ‘Specialised’ element of this pathway (Mother and Baby in-patient Units) since April 2013. A specification for these specialised perinatal services was developed by the NHS England specialised perinatal Clinical Reference Group, which comprises representatives from across the country with both clinical members and patients/Carers. The specification was subject to national consultation and NHS England work with the Royal College to develop quality standards.” Source location 2014-0239-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 Clinical Commissioning Groups commission local perinatal mental health services and should address concerns about Wirral provision.
Verbatim wording from the response “Specialised Perinatal Mental Health Services (Mother and Baby Units) are a part of a wider network of services that provide care for this patient group and the commissioning of the ‘specialist’ (local) and ‘specialised’ (national) pathway is a responsibility shared between NHS England, Clinical Commissioning Groups and Local Authorities.” Source location 2014-0239-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 Regional commissioning and the Manchester Mother and Baby Unit are considered sufficient for North West demand, with neighbouring units available when necessary.
Verbatim wording from the response “Mother and Baby Units fall under this category of service and are therefore commissioned on a regional, rather than local, basis. This ensures that those very specialised qualifications, clinical skills and experience required to treat the patient group can be maintained and that the service can be commissioned cost-effectively, making best use of public funds. If there were to be a Mother and Baby unit in every major city, the use of the service by that city’s population would be minimal and clinicians would quickly lose their specialist knowledge and skills because of infrequent use. It would also be inefficient because of the low demand.” Source location 2014-0239-Response-by-Department-of-Health
Open published response
Concerns raised 6 Failure to retain and make essential observation documentation available View source Failure of communication in coordinating family notification of death View source Failure of observation records to specify and capture who and when observations are completed View source Lack of detailed guidance on access to and type of ligature cutters View source Failure to provide essential patient and emergency-equipment information to external emergency services View source Failure to ensure immediately available ligature cutters in the secure clinic View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mark Darren Bartholomew · 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
Mark Darren Bartholomew, who had a longstanding diagnosis of paranoid schizophrenia and was detained in hospital after transfer from prison, died by hanging on 25 July 2013 during a routine observation check. Concerns included an inadequate response to emergency services, the absence of the ligature cutter needed to release him promptly, and insufficient detail in observation records.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to retain and make essential observation documentation available
Wider context from the report “1. Notwithstanding the Trust’s policy entitled ’2999 Procedure’ the purpose of which is to advise staff of process during a psychiatric emergency, it was clear that the response to external emergency services was inadequate. More particularly:-
• The informant was unable to provide the emergency controller with either the name or age of the patient; whether he was still breathing; and whether a defibrillator was available.
• Essential documentation (the observation record for the relevant 24 hour period) was mislaid and not available for the Inquest.
• Originally, a joint visit by both Police and Trust staff was arranged for the purpose of relaying news of the deceased’s death to the family. By reason of a lack of communication, the family were notified following an attendance by uniformed officers whereupon the deceased’s Mother telephoned the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of communication in coordinating family notification of death
Wider context from the report “1. Notwithstanding the Trust’s policy entitled ’2999 Procedure’ the purpose of which is to advise staff of process during a psychiatric emergency, it was clear that the response to external emergency services was inadequate. More particularly:-
• The informant was unable to provide the emergency controller with either the name or age of the patient; whether he was still breathing; and whether a defibrillator was available.
• Essential documentation (the observation record for the relevant 24 hour period) was mislaid and not available for the Inquest.
• Originally, a joint visit by both Police and Trust staff was arranged for the purpose of relaying news of the deceased’s death to the family. By reason of a lack of communication, the family were notified following an attendance by uniformed officers whereupon the deceased’s Mother telephoned the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 specify and capture who and when observations are completed
Wider context from the report “3. The Trust has a documented Observation Policy. Whilst the Policy requires records to be contemporaneously recorded, it does not specify how this is to be achieved . The actual observation sheet apparently in use at present indicates a poor level of detail as to who and when it is completed and in its present format would not withstand a rigorous audit .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 detailed guidance on access to and type of ligature cutters
Wider context from the report “2. Ligature Cutters – The Consultant Forensic Pathologist, ████████ confirmed in evidence that time was very much of the essence. Specifically he stated ‘following application, pressure through the ligature, and unconsciousness may ensue within a few seconds with death within minutes’
The registered nurse in charge of the ward ran to the scene, but then had to retrieve the ligature cutters which should have been in the front pocket of a bag attached to a hook on the wall in the secure clinic. The ligature cutter had in fact been used following an incident a week earlier and had not been returned. Despite a regime of daily checking, the absence had gone unnoticed. The Nurse-in-Charge immediately retrieved the ward scissors from a locked drawer and the ligature was subsequently released albeit approximately 2 minutes later. To the credit of the Trust, the practice of daily checks for equipment has now been superseded by a check at the commencement of each shift.
Although alerted to Department of Health guidance from 2007, I can find no detailed guidance with regard to either access to or the type of ligature cutter to be used. Evidence was given to the Inquest by the Senior Investigating Officer of Greater Manchester Police who made reference to the use of an implement carried in a pouch by Custody Sergeants within the Custody Office of designated Police Stations. The Senior Investigating Officer was not aware of any untoward incident arising from the use of such an implement which according to the Officer cannot be used to inflict harm on a third person. If the Security Nurse who had initially attended had been carrying such an implement, the ligature would have been released within a matter of seconds rather than minutes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide essential patient and emergency-equipment information to external emergency services
Wider context from the report “1. Notwithstanding the Trust’s policy entitled ’2999 Procedure’ the purpose of which is to advise staff of process during a psychiatric emergency, it was clear that the response to external emergency services was inadequate . More particularly:-
• The informant was unable to provide the emergency controller with either the name or age of the patient; whether he was still breathing; and whether a defibrillator was available.
• Essential documentation (the observation record for the relevant 24 hour period) was mislaid and not available for the Inquest.
• Originally, a joint visit by both Police and Trust staff was arranged for the purpose of relaying news of the deceased’s death to the family. By reason of a lack of communication, the family were notified following an attendance by uniformed officers whereupon the deceased’s Mother telephoned the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 immediately available ligature cutters in the secure clinic
Wider context from the report “2. Ligature Cutters – The Consultant Forensic Pathologist, ████████ confirmed in evidence that time was very much of the essence. Specifically he stated ‘following application, pressure through the ligature, and unconsciousness may ensue within a few seconds with death within minutes’
The registered nurse in charge of the ward ran to the scene, but then had to retrieve the ligature cutters which should have been in the front pocket of a bag attached to a hook on the wall in the secure clinic . The ligature cutter had in fact been used following an incident a week earlier and had not been returned. Despite a regime of daily checking, the absence had gone unnoticed. The Nurse-in-Charge immediately retrieved the ward scissors from a locked drawer and the ligature was subsequently released albeit approximately 2 minutes later . To the credit of the Trust, the practice of daily checks for equipment has now been superseded by a check at the commencement of each shift.
Although alerted to Department of Health guidance from 2007, I can find no detailed guidance with regard to either access to or the type of ligature cutter to be used. Evidence was given to the Inquest by the Senior Investigating Officer of Greater Manchester Police who made reference to the use of an implement carried in a pouch by Custody Sergeants within the Custody Office of designated Police Stations. The Senior Investigating Officer was not aware of any untoward incident arising from the use of such an implement which according to the Officer cannot be used to inflict harm on a third person. If the Security Nurse who had initially attended had been carrying such an implement, the ligature would have been released within a matter of seconds rather than minutes.
” Open source report
15 May 2014 Gary Bradshaw · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 12 Incomprehensive and inefficient hospital notes View source Misinterpretation of blood or urine test results communicated to the General Practitioner View source Discharge before completion of full investigations View source Prescribing and administering Bendroflumethiazide before blood test results were known View source Subjective interpretation of Early Warning Scores View source Failure of the laboratory to flag blood-calcium levels from 3.0mmol/l View source Failure to keep fluid balance charts properly View source Failure of the electronic system to reveal notes of a previous admission View source Failure to consider referral to an endocrine surgeon View source Delay in initial diagnosis of kidney stones View source Failure of ward-to-ITU patient escalation View source Failure to complete or report ordered blood tests View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gary Bradshaw · 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
Gary Bradshaw attended hospital with groin pain and kidney stones, later developed hyperparathyroidism and died during a hospital admission. The report identified concerns including delays and errors in diagnosis and testing, prescribing bendroflumethiazide before blood-test results, discharge before full investigation, inadequate escalation and fluid monitoring, and incomplete clinical records.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Incomprehensive and inefficient hospital notes
Wider context from the report “10. Hospital notes and especially those in the E.D. (on the ADVANTIS SYSTEM) seem to have been less than comprehensive and efficient. The emergency doctor fed the patient’s ‘number’ into the computer but it did not reveal the notes of the previous admission.(Stockport NHS Trust)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Misinterpretation of blood or urine test results communicated to the General Practitioner
Wider context from the report “4. There was a misunderstanding or misinterpretation of the results to the General Practitioner as to whether these results related to blood or urine tests .(Stockport NHS Trust)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Discharge before completion of full investigations
Wider context from the report “5. The patient was discharged from the hospital on the 27th June 2012 rather than being retained as an in-patient whilst full investigations were carried out ; again a practice which the expert witness felt to be inappropriate (Stockport NHS Trust)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Prescribing and administering Bendroflumethiazide before blood test results were known
Wider context from the report “3. The above blood tests were ordered but the patient was prescribed and administered Bendroflumethiazide before the results were known , something which the expert witness described as contra-indicated .(Stockport NHS Trust and 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 Subjective interpretation of Early Warning Scores
Wider context from the report “12. There seemed to have been a very subjective interpretation of the EWS at the hospital by using the ‘manual’ assessment method. I was told that an electronic version is being rolled out. I would hope that this can be sooner rather than later as it will give a far better and more objective assessment of the Early Warning Scores. (Stockport NHS Trust and 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 the laboratory to flag blood-calcium levels from 3.0mmol/l
Wider context from the report “8. The hospital laboratory only ‘flag-up’ the blood-calcium levels exceed 3.5mmol/l or more of serum calcium. The expert witness opined that this should occur at levels of 3.0mmol/l , and that this should be the National standard.(Stockport NHS Trust and The Secretary of State)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to keep fluid balance charts properly
Wider context from the report “7. Fluid balance charts were not kept, or not kept properly , on various occasions during the in-patient stays (Stockport NHS Trust)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 electronic system to reveal notes of a previous admission
Wider context from the report “10. Hospital notes and especially those in the E.D. (on the ADVANTIS SYSTEM) seem to have been less than comprehensive and efficient. The emergency doctor fed the patient’s ‘number’ into the computer but it did not reveal the notes of the previous admission .(Stockport NHS Trust)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to consider referral to an endocrine surgeon
Wider context from the report “6. During the subsequent admission on the 29th June no consideration was given to referring Mr Bradshaw to an endocrine surgeon . (Stockport NHS Trust)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delay in initial diagnosis of kidney stones
Wider context from the report “1. There was a considerable delay in the initial diagnosis that he was suffering with kidney stones, between May 2011 and March 2012. (Stockport NHS Trust)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 ward-to-ITU patient escalation
Wider context from the report “9. The system of escalation of patients from the wards to the ITU did not seem to be in place or alternatively did not seem to have worked as it ought to have done when the ward sister wanted to send the patient to the ITU (Stockport NHS Trust).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to complete or report ordered blood tests
Wider context from the report “2. At the consultation in March 2012 both blood and urine tests were ordered but apparently only the urine tests were done and /or reported , thus his hypercalciuria was seen but not his hypercalcaemia (Stockport NHS Trust)
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual NHS Trusts are responsible for reviewing their own standards for laboratory result reporting and alerts.
Verbatim wording from the response “In response to your concerns about the reporting of blood test results, NICE do not stipulate laboratory reference values or ‘flags’ on when to alert clinicians to blood test results. As this is not something that falls within NICE’s remit, it is for individual NHS Trusts to review their own standards.” Source location 2014-0232-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 No Summary Care Record flag for prescribing before test results is planned; the matter is left to doctors’ clinical and professional judgement.
Verbatim wording from the response “With regard to the third concern above, I assume you are referring to the Summary Care Record (SCR). I can confirm that flag system functionality is not within existing requirements for the SCR system nor are there any current plans for SCRs or SCR systems to introduce “an in-built ‘flag’ which would highlight to a doctor that he or she was prescribing drugs before the requested blood/urine test results had been received. This is a matter best left to the clinical and professional judgement of the doctor involved, with first-hand knowledge of the patient’s circumstances.” Source location 2014-0232-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 NICE does not stipulate laboratory reference values or alert thresholds because this falls outside its remit.
Verbatim wording from the response “In response to your concerns about the reporting of blood test results, NICE do not stipulate laboratory reference values or ‘flags’ on when to alert clinicians to blood test results. As this is not something that falls within NICE’s remit, it is for individual NHS Trusts to review their own standards.” Source location 2014-0232-Response-by-Department-of-Health
Open published response
Concerns raised 3 Inconsistent referral of unwell A&E attenders to a psychiatrist View source Lack of age-appropriate observation guidance for children and adolescents in specialist mental health units View source Lack of formal communication and information-transfer protocols between healthcare establishments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Miss Samiyo Sahra Shih Farah · 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
Miss Samiyo Sahra Shih Farah, who had depression and a history of self-harm, was found unresponsive with a ligature around her neck on 30 December 2012 and was pronounced dead. The principal concerns were the lack of national guidance on observation of children and adolescents in specialist mental health units, inadequate formal protocols for communication during transfers between private and NHS providers, and inconsistent referral arrangements following her attendances at A&E.
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 Inconsistent referral of unwell A&E attenders to a psychiatrist
Wider context from the report “3) There appears to have been an inconsistency of approach following Miss Farah’s admissions to A & E. She was referred directly to a Psychiatrist on the second attendance when she was clearly unwell but had not managed to self-harm but was not on the first attendance when she had taken an overdose . This also raises the question as to whether she ought to have been referred (to a Psychiatrist) on the 31st October 2012 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 age-appropriate observation guidance for children and adolescents in specialist mental health units
Wider context from the report “1) Observation protocol - there is no national guidance/policy on the observation of children and adolescents within specialist mental health units . At present, clinicians are forced to adopt/adapt policies applied to adults with mental health issues . The care needs of young people are quite different to those of adults .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of formal communication and information-transfer protocols between healthcare establishments
Wider context from the report “2) Communication/contact between transferring establishments - there is no formal policy/protocol in use/between the private sector and the NHS detailing steps that should be taken (and by whom) upon transfer of patients between sectors , thus risking that not all key information (both verbal and written) is properly communicated before, during and after transfer . Whilst progress is being made in this regard at local level following the death of Miss Farah (and may well be the basis upon which any national policy/protocol might be formulated) there is currently no communication/transfer protocol in existence . This also potentially impacts upon all other healthcare sector providers e.g. the acute sector, hospital to care home, acute to rehabilitation/community services etc.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual NHS Trusts are responsible for developing transfer protocols with private-sector providers, reflecting provider variation and patient factors.
Verbatim wording from the response “With regard to transfer protocols between the NHS and the private sector, each Trust currently develops their own. This is because the private sector is not uniform in its approach and it is necessary to take account of this variance as well as relevant patient factors. In general, Trusts would be expected to establish good working relationships and transfer arrangements with those private sector providers with whom they regularly deal.” Source location 2014-0202-Response-by-Department-of-Health
Open published response
Concerns raised 3 Lack of an accelerated Accident and Emergency pathway for individuals suffering neutropenic sepsis View source Lack of urologist management of catheterised patients View source Failure to limit catheterisation frequency 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
Stephen Anthony Allardice Widman · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Anthony Allardice Widman had a history of rectal carcinoma and was repeatedly catheterised. An inappropriately placed catheter was considered likely, infection developed, and he became weakened by pneumonia before dying from sepsis associated with a urinary tract infection and pyelonephritis. Concerns included delays in treating neutropenic sepsis in Accident and Emergency and frequent catheterisation without urological management.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of an accelerated Accident and Emergency pathway for individuals suffering neutropenic sepsis
Wider context from the report “1. There should be an accelerated pathway for individuals suffering neuropenic sepsis so they are dealt with promptly . On the evidence at this Inquest it was inappropriate for the deceased to sit for several hours in the Accident and Emergency Department .
2. The deceased was catheterised too frequently without the management of a urologist.
Evidence was received that there is an advantage in treating patients promptly on arrival at Accident and Emergency and that treatment could be expedited if patients were issued with a card noting their vulnerability and bringing with them a contact telephone number.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 urologist management of catheterised patients
Wider context from the report “1. There should be an accelerated pathway for individuals suffering neuropenic sepsis so they are dealt with promptly. On the evidence at this Inquest it was inappropriate for the deceased to sit for several hours in the Accident and Emergency Department.
2. The deceased was catheterised too frequently without the management of a urologist .
Evidence was received that there is an advantage in treating patients promptly on arrival at Accident and Emergency and that treatment could be expedited if patients were issued with a card noting their vulnerability and bringing with them a contact telephone number.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 limit catheterisation frequency
Wider context from the report “1. There should be an accelerated pathway for individuals suffering neuropenic sepsis so they are dealt with promptly. On the evidence at this Inquest it was inappropriate for the deceased to sit for several hours in the Accident and Emergency Department.
2. The deceased was catheterised too frequently without the management of a urologist.
Evidence was received that there is an advantage in treating patients promptly on arrival at Accident and Emergency and that treatment could be expedited if patients were issued with a card noting their vulnerability and bringing with them a contact telephone number.
” Open source report
29 Apr 2014 Janet BLACKMAN · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 4 Failure to apply DVT avoidance policy to patients in psychiatric units View source Failure to provide seamless physical and mental healthcare including DVT prophylaxis within a single unit View source Failure to apply DVT prophylaxis policy and clerking to patients entering psychiatric units View source Failure of psychiatric units to deliver required physical healthcare 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
Janet BLACKMAN · 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
Janet Blackman became unwell and was treated for hyperthyroidism and low sodium before being transferred between a medical unit and a psychiatric unit. She died after developing a pulmonary embolus due to deep calf venous thrombosis; the report noted that the psychiatric unit could not administer the prescribed heparin prophylaxis and raised concerns about continuity of physical healthcare and application of DVT prevention policy in psychiatric settings.
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 apply DVT avoidance policy to patients in psychiatric units
Wider context from the report “(3) By way of emphasis and duplication, that if anything, the NICE recommendations and policy for DVT avoidance is as relevant to patients being treated in psychiatric units as in any other units providing patient 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 provide seamless physical and mental healthcare including DVT prophylaxis within a single unit
Wider context from the report “(4) It should be possible to develop a system enabling a seamless delivery of care covering both the physical and mental health treatment including DVT Prophylaxis to a patient in a single unit without the need to move patients physically from one unit to another , even if different aspects of care are delivered by different trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 apply DVT prophylaxis policy and clerking to patients entering psychiatric units
Wider context from the report “(2) It would seem that the logic of the DVT prophylactic policy as recommended by NICE is not applied to those patients coming into the psychiatric units – or if it were then Mrs Blackman would have been subject to the same clerking process on each of her admissions to the HKU and thereafter would have been able to receive the prophylaxis care that had been prescribed for her in the AMU.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 psychiatric units to deliver required physical healthcare
Wider context from the report “(1) The HKU like other units dedicated to the delivery of essentially psychiatric care are not able to deliver at least some of the elements required of the patient for her physical healthcare .
” Open source report
14 Apr 2014 Paul Michael Ashton · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Lack of protocols and guidelines for perioperative management of heart transplant patients undergoing non-cardiac surgery View source Unavailability of Isoprenaline for resuscitation of heart transplanted patients View source Failure to communicate the source and importance of Isoprenaline use for resuscitation of heart transplanted patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Michael Ashton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Michael Ashton died during a right knee arthroscopy under general anaesthesia after suffering a cardiac arrest. The concerns included the absence of hospital protocols for the perioperative management of heart-transplanted patients undergoing non-cardiac surgery, and issues concerning the availability and use of Isoprenaline during resuscitation.
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 protocols and guidelines for perioperative management of heart transplant patients undergoing non-cardiac surgery
Wider context from the report “(2) I have concerns with regard to the following:-
i. The absence of protocols and guidelines in Hospitals dealing with the perioperative management of heart transplanted patients due to undergo or undergoing non cardiac surgery . Such a protocol or guidelines could summarise issues that need to be considered when assessing and caring for a patient with a transplanted heart and the elements of such protocol or guidelines could include the following:
a) Pre-operative assessment
b) Liaising with the transplant unit the patient is under for follow up.
c) Guidance on risk
d) Benefit discussion with the patient and consent process
e) Perioperative management (anaesthetic technique(s), monitoring, drugs and their doses and fluid balance etc.)
f) Postoperative care
g) Strategies for perioperative complications including resuscitation procedures and the use of Isoprenaline.
ii. The source, availability and the use of Isoprenaline in Hospitals and by health professionals in relation to the resuscitation of heart transplanted patients. Isoprenaline is a drug that is considered to be the best anti-bradycardic agent in denervated or transplanted patients and disappeared from the United Kingdom formulary about 10 years ago. It is therefore assumed that it is not available anymore and that Adrenaline is the only drug effective in bradycardia in denervated hearts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Isoprenaline for resuscitation of heart transplanted patients
Wider context from the report “(2) I have concerns with regard to the following:-
i. The absence of protocols and guidelines in Hospitals dealing with the perioperative management of heart transplanted patients due to undergo or undergoing non cardiac surgery. Such a protocol or guidelines could summarise issues that need to be considered when assessing and caring for a patient with a transplanted heart and the elements of such protocol or guidelines could include the following:
a) Pre-operative assessment
b) Liaising with the transplant unit the patient is under for follow up.
c) Guidance on risk
d) Benefit discussion with the patient and consent process
e) Perioperative management (anaesthetic technique(s), monitoring, drugs and their doses and fluid balance etc.)
f) Postoperative care
g) Strategies for perioperative complications including resuscitation procedures and the use of Isoprenaline.
ii. The source, availability and the use of Isoprenaline in Hospitals and by health professionals in relation to the resuscitation of heart transplanted patients . Isoprenaline is a drug that is considered to be the best anti-bradycardic agent in denervated or transplanted patients and disappeared from the United Kingdom formulary about 10 years ago . It is therefore assumed that it is not available anymore and that Adrenaline is the only drug effective in bradycardia in denervated hearts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the source and importance of Isoprenaline use for resuscitation of heart transplanted patients
Wider context from the report “v. The supply of Isoprenaline is not available in the United Kingdom and the source of the supply and the importance of the use of Isoprenaline in the resuscitation of heart transplanted patients should be brought to the attention of all hospitals and health professionals in the United Kingdom .
” 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 Request UKMI to produce a shortage memo on isoprenaline availability and alternatives.
Verbatim wording from the response “However, the Department of Health is aware that there have been problems with the availability of isoprenaline and I can confirm that as a result of the current problems, the Department of Health asked the NHS UK Medicines Information service (UKMI) to produce a “Shortage Memo” which summarises the situation and advises on alternatives. This was sent out to hospitals and uploaded to the UKMI website, at the following address, on 24th April 2014:” Source location 2014-0170-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 communication between cardiac centres and operating hospitals should make isoprenaline available for high-risk heart transplant procedures.
Verbatim wording from the response “NHS England also believes that it is likely that isoprenaline is used by all cardiac surgical centres, both adult and paediatric, and that it is also available in private hospitals performing cardiac surgery. It is therefore unlikely to be stocked by hospitals that do not perform cardiac surgery or tertiary cardiology. Good communication between the cardiac centre and the hospital operating on the heart transplant patient should enable supplies to be made available to cover specific procedures in high risk patients.” Source location 2014-0170-Response-by-Department-of-Health
Open published response
Concerns raised 3 Failure to provide supervision proportionate to identified competence concerns for locum consultants View source Failure to use robust processes for signing off locum consultants as competent for independent practice View source Failure to use robust processes for appointing locum consultants 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
Lalitab en Jayantibhai Patel · 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
Mrs Patel underwent elective laparoscopic cholecystectomy on 4 May 2012, during which inappropriate dissection damaged a vessel near the common bile duct. The vessel ruptured, causing a massive secondary haemorrhage, subsequent complications and hypoxic brain injury, followed by her death on 20 December 2012; the principal concern was inadequate systems for assessing and supervising locum consultant surgeons, creating a risk of similar events elsewhere.
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 supervision proportionate to identified competence concerns for locum consultants
Wider context from the report “(1) The surgeon who had responsibility for the elective cholecystectomy was a Locum Consultant Surgeon and was in the second week of his 4 weeks contract. Evidence was heard that he had been appointed via an agency following which he undertook two practical assessments at the University Hospitals Leicester. In summary, there were two main issues highlighted by both assessing Consultants on two separate days resulting in a decision to restrict the Locum Consultant Surgeon to conducting routine laparoscopic cholecystectomies. However, as this was a Consultant grade Locum, no other supervision was provided in respect of the cases under his clinical management.
Evidence revealed that the systems in place at the material time for signing off a locum Consultant as competent to undertake independent practice were not as robust as they should have been.
The inquest heard that University Hospitals Leicester have now changed their recruitment process for Locums and that Locums must be recruited by the ‘Locum Bookers’ team in accordance with Trust policy. In addition the processes for signing off a locum consultant as competent are more robust.
However, it is understood that in other areas the practice for appointing locums is not so robust and mirrors the practice undertaken at the material time. Accordingly, there is a real risk that what happened in this case could happen elsewhere.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to use robust processes for signing off locum consultants as competent for independent practice
Wider context from the report “(1) The surgeon who had responsibility for the elective cholecystectomy was a Locum Consultant Surgeon and was in the second week of his 4 weeks contract. Evidence was heard that he had been appointed via an agency following which he undertook two practical assessments at the University Hospitals Leicester. In summary, there were two main issues highlighted by both assessing Consultants on two separate days resulting in a decision to restrict the Locum Consultant Surgeon to conducting routine laparoscopic cholecystectomies. However, as this was a Consultant grade Locum, no other supervision was provided in respect of the cases under his clinical management.
Evidence revealed that the systems in place at the material time for signing off a locum Consultant as competent to undertake independent practice were not as robust as they should have been.
The inquest heard that University Hospitals Leicester have now changed their recruitment process for Locums and that Locums must be recruited by the ‘Locum Bookers’ team in accordance with Trust policy. In addition the processes for signing off a locum consultant as competent are more robust.
However, it is understood that in other areas the practice for appointing locums is not so robust and mirrors the practice undertaken at the material time. Accordingly, there is a real risk that what happened in this case could happen elsewhere.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to use robust processes for appointing locum consultants
Wider context from the report “(1) The surgeon who had responsibility for the elective cholecystectomy was a Locum Consultant Surgeon and was in the second week of his 4 weeks contract. Evidence was heard that he had been appointed via an agency following which he undertook two practical assessments at the University Hospitals Leicester. In summary, there were two main issues highlighted by both assessing Consultants on two separate days resulting in a decision to restrict the Locum Consultant Surgeon to conducting routine laparoscopic cholecystectomies. However, as this was a Consultant grade Locum, no other supervision was provided in respect of the cases under his clinical management.
Evidence revealed that the systems in place at the material time for signing off a locum Consultant as competent to undertake independent practice were not as robust as they should have been.
The inquest heard that University Hospitals Leicester have now changed their recruitment process for Locums and that Locums must be recruited by the ‘Locum Bookers’ team in accordance with Trust policy. In addition the processes for signing off a locum consultant as competent are more robust.
However, it is understood that in other areas the practice for appointing locums is not so robust and mirrors the practice undertaken at the material time. Accordingly, there is a real risk that what happened in this case could happen elsewhere.
” Open source report
8 Apr 2014 Audrey Lily Kelly · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Failure to provide out-of-hours and hospital emergency department clinicians with direct access to patients’ GP notes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Audrey Lily Kelly · 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
Audrey Lily Kelly complained of abdominal pain on 17 November 2013, was prescribed Trimethoprim by an out-of-hours doctor who could not access her GP medical notes, and was found deceased at home two days later. The investigation concluded that she died from natural causes. The principal concern was that out-of-hours services and hospital emergency departments could not access patients’ GP notes, including allergy information, which was considered a serious procedural lapse that could put lives at risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide out-of-hours and hospital emergency department clinicians with direct access to patients’ GP notes
Wider context from the report “During the course of the evidence it was made very clear to me by the attending doctor who prescribed the medication and also by the nurse who took the call at the Out of Hours service that they could not /are not allowed to obtain and see the electronic notes held by the patient's own GP . This fact was backed up by a senior administrator of the Out of Hours service who reiterated that neither they nor the hospital Emergency Departments, have direct access to GP Notes .
It seems to me that this is a serious lapse in the procedures and will inevitably lead to further lives being lost when, if the notes were available, those lives might be saved.
In the case of the Out of Hours service it seems particularly absurd that these notes are not available when in fact the Out of Hours doctor is deputising for that very GP who
not allowing access to the notes.
It would appear therefore that there is an immediate need for directions to be issued to ALL OUT OF HOURS PROVIDERS and the appropriate Clinical Commissioning Groups to the effect that there must be free and unfettered access to ALL the GP notes in these circumstances.
” 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 Work with Mastercall to provide fit-for-purpose mobile access to relevant patient information at the point of care through a governed improvement project.
Verbatim wording from the response “Stockport CCG is already engaged in continual improvement work in this area. However, as a result of this investigation, the CCG is also planning the following measures:” Source location 2014-0155-Response-by-Department-of-Health2
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 Seek formal assurance from Mastercall on new-starter processes and contingencies for practitioners without NHS Smartcards.
Verbatim wording from the response “Stockport CCG is already engaged in continual improvement work in this area. However, as a result of this investigation, the CCG is also planning the following measures:” Source location 2014-0155-Response-by-Department-of-Health2
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 Map and analyse shared-record access processes and systems with Mastercall to identify and mitigate further risks.
Verbatim wording from the response “Stockport CCG is already engaged in continual improvement work in this area. However, as a result of this investigation, the CCG is also planning the following measures:” Source location 2014-0155-Response-by-Department-of-Health2
Open published response
1 Apr 2014 Oliver George Hiscutt · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Lack of mandatory formal paediatric training for GPs 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
Oliver George Hiscutt · 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
Oliver George Hiscutt developed a Group A beta-haemolytic streptococcal infection with a retropharyngeal abscess, followed by catastrophic haemorrhage and cardiac arrests; he died on 7 October 2012. The report raised concern that formal paediatric or child-health training is not mandatory for GPs and that exposure to acute paediatrics during GP training is limited.
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 mandatory formal paediatric training for GPs
Wider context from the report “Currently it is not mandatory for GPs to undertake formal paediatric / child health training. Facing the Future (2011) states that there are currently 10 000 GP trainees in the country and less than 25% of them will undertake any paediatric placement during their training. GP trainees who do undertake a paediatric placement during their training gain a range of educational benefits such as the development of skills in spotting the sick child, specialist management of children with long term conditions and multi disciplinary team working.
The Royal College of General Practitioners and the Royal College of Paediatrics and Child Health strongly support all GPs having exposure to acute paediatrics as part of their vocational training. Offering every GP trainee a hospital post in paediatrics within the current 3 year specialty training programme is undeliverable. The Royal College of General Practitioners makes the case that there should be an enhanced 4 year programme of GP training and that all GPs should undertake specialist led paediatric training. Specialist led paediatric training will ensure that future GPs have the skills and experience they need to assess and respond effectively and safely to sick children, to better co-ordinate the care of children with long term conditions and to safeguard those at risk.
” Open source report
25 Mar 2014 Caroline Louise Pilkington · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1 Lack of control and restraint training for ambulance service personnel View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Caroline Louise Pilkington · 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
Caroline Louise Pilkington was found apparently suffering from a fit at home on 25 April 2013 and required restraint to be removed safely, with police assistance called because ambulance personnel were not trained in control and restraint techniques. The inquest concluded that her death was due to an accident, with the medical cause recorded as propranolol toxicity. The report raised concerns that involving police in such situations could result in clinically untrained officers dealing with unwell patients and could delay removal to hospital, potentially causing harm.
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 control and restraint training for ambulance service personnel
Wider context from the report “North West Ambulance Service personnel are not trained in control and restraint techniques. Evidence was therefore given at the inquest that it was necessary for them to call the police service to assist them in dealing with patients who are unwell where the use of such techniques is required. This is so despite the fact that other clinical personnel, for example Mental Health nurses, are trained in such techniques. In the case of Miss Pilkington this resulted in three paramedics having to call for assistance from the police service. Evidence revealed that calling the police in these circumstances results in patients who are physically and/or mentally unwell being dealt with by the police service, who, although they are trained in control and restraint techniques, are not clinically trained to deal with such patients. In addition, further evidence was given that the involvement of the police service in these cases not only potentially results in inappropriate removal of police officers from their core policing duties, but also potentially results in harm to patients being caused by delaying their removal to hospital.
” 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 Training all ambulance staff in advanced control and restraint is not feasible because they could not maintain the specialised skills through regular practice.
Verbatim wording from the response “• Advanced control and restraint is an extremely specialised skill, which, due to the risks involved, requires extensive training and regular practice. As ambulance staff are not commonly tasked with situations which require” Source location 2014-0269-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 Collaborative ambulance-police working and police assistance provide the safest, timeliest and least restrictive response to patients requiring advanced restraint.
Verbatim wording from the response “• A joint protocol was developed between the North West Region Police Forces and NWAS in March 2012 which supports inter-agency working and the appropriate use of shared resources to deliver the best possible care for patients who lack capacity. All five police forces in the North West have agreed to the protocol.” Source location 2014-0269-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 policies and training are considered sufficient, with police involvement decided case by case and no general need for change identified.
Verbatim wording from the response “NWAS has confirmed that a regional protocol is in place that all police forces it works with, including Greater Manchester Police, have agreed to. This protocol is under review. However, at the most recent North West Police Regional Mental Health Forum, NWAS presented and discussed the findings from your request concerning the death of Caroline Pilkington. None of the police forces believed there was a need to change the current policy or reduce the involvement of the police in managing those patients who required more than minimal restraint.” Source location 2014-0269-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 Further advanced restraint training is not supported because its rarity would make safe skill maintenance difficult and could increase harm risks.
Verbatim wording from the response “As the need for ambulance personnel to use restraint techniques is comparatively rare, NWAS believes that the need to train all ambulance staff in more advanced or specialised restraint techniques is not demonstrated. Even if all staff were to be trained, it would be difficult to maintain their skills sufficiently (because of the low incidence of use) to safely restrain these types of patients when the skills were called for. The risk is that poorly or inappropriately applied restraint techniques could cause harm to the patient or to staff.” Source location 2014-0269-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 Training ambulance staff in control and restraint is outside the Department of Health’s responsibility.
Verbatim wording from the response “Firstly, it needs to be understood that the training of ambulance staff in control and restraint techniques is not a matter for which the Department of Health (DH) is responsible. Ambulance staff, for example emergency care assistants, emergency care practitioners and paramedics, are health professionals and are trained as such. The actual training that ambulance staff require and receive in control and restraint is a matter for the NHS Trust concerned, and not DH.” Source location 2014-0269-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 The relevant NHS Trust is responsible for determining and providing ambulance staff control and restraint training.
Verbatim wording from the response “Firstly, it needs to be understood that the training of ambulance staff in control and restraint techniques is not a matter for which the Department of Health (DH) is responsible. Ambulance staff, for example emergency care assistants, emergency care practitioners and paramedics, are health professionals and are trained as such. The actual training that ambulance staff require and receive in control and restraint is a matter for the NHS Trust concerned, and not DH.” Source location 2014-0269-Response-by-Department-of-Health2
Open published response
20 Mar 2014 Jackson J Chadd · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Lack of effective supervision of non-career grade paediatricians without previous experience View source Lack of independent consultant assessment of paediatric admissions outside normal working hours View source Failure to acknowledge or act on parent concerns View source Lack of consultant supervision of out-of-hours on-call paediatric trainees View source Lack of effective application of national guidelines for assessment and investigation of fever in children less than one year of age View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jackson J Chadd · 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
Jackson became unwell at home with fever, poor feeding, diarrhoea, a rash and abnormal observations, and was discharged from A&E with a diagnosis of gastroenteritis. He returned in septic shock and died despite resuscitation; the medical cause of death was fulminant meningococcal infection. Concerns included inadequate supervision and assessment, failure to apply fever guidelines, and failure to act on a parent’s concerns.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of effective supervision of non-career grade paediatricians without previous experience
Wider context from the report “1. Lack of effective supervision of a non-career grade paediatrician with no previous experience
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of independent consultant assessment of paediatric admissions outside normal working hours
Wider context from the report “3. Lack of independent consultant assessment of paediatric admissions into Frimley Park Hospital outside normal working hours
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to acknowledge or act on parent concerns
Wider context from the report “5. Failure to acknowledge or act on the concerns of a parent
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 consultant supervision of out-of-hours on-call paediatric trainees
Wider context from the report “2. Lack of consultant supervision of ‘out of hours’ on-call paediatric trainees
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 effective application of national guidelines for assessment and investigation of fever in children less than one year of age
Wider context from the report “4. Lack of effective application of national guidelines for assessment and investigation of fever in children less than one year of age
” Open source report
Concerns raised 9 Failure to make case-specific referrals through the single point of entry process View source Failure to refer patients to psychiatric services for expert diagnosis, opinion, management and treatment planning View source Unnecessarily bureaucratic and deterrent processes for accessing mental health services View source Unavailability of direct referral to in-house community-based psychiatrists for new patients View source Failure to ensure medically qualified practitioner management of single point of entry triage View source Restrictions on cross-Clinical Commissioning Group referrals without special approval View source Failure of contemporaneous record keeping to support clinical recollections View source Failure to use recognised assessment tools in clinical evaluation View source Failure to assess medication appropriateness in light of patients’ mental health history View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Gary Chatburn · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Gary Chatburn had a significant history of mental health problems, including depression, probable bipolar disorder, alcohol misuse and fluctuating mood. He was found hanging from a tree on 18 October 2013, and the inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included the lack of referral to psychiatric services, the GP-led diagnosis and treatment, medication management, informal follow-up, record keeping and barriers in accessing 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 make case-specific referrals through the single point of entry process
Wider context from the report “4. That the GP felt it was sufficient for him to simply discuss the deceased’s care with the practice-based community psychiatrist and thus, no need for a referral to the single point of entry process . Such discussions were not necessarily case specific in any event but rather, general in nature .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 refer patients to psychiatric services for expert diagnosis, opinion, management and treatment planning
Wider context from the report “1. That there was no referral made by the GP to the Psychiatric services for an expert diagnosis/opinion/management and treatment plan . The GP considered that there was no need, as he felt clinically competent to manage the deceased’s care and in any event, had a special interest in mental health, although he conceded that he was not formally recognised as a GP with a Special Interest (‘GPwSPi’) and whilst confident in his ability to manage the deceased’s care, his area of special interest was in fact the management of addictions.
Irrespective, he felt that he was best placed to assess, diagnose and treat the deceased on the basis that had he referred Mr Chatburn to the single point of entry system, the person ‘triaging’ would not have been medically qualified and would not have known the deceased as well as he felt 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 Unnecessarily bureaucratic and deterrent processes for accessing mental health services
Wider context from the report “7. That the processes GPs are expected to use in order to access mental health services for their patients are unnecessarily bureaucratic and deterrent . GPs can no longer simply contact a Consultant Psychiatrist directly for advice. Everything must pass through the single point of entry.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 direct referral to in-house community-based psychiatrists for new patients
Wider context from the report “3. That the GP was unable to refer the deceased, as a new patient, directly to the in-house community based psychiatrist , thus effectively defeating the object.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 medically qualified practitioner management of single point of entry triage
Wider context from the report “8. That the ‘triage’ process used by the single point of entry system is not always managed by a medically qualified practitioner – this being a vital stage in determining diversion/allocation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Restrictions on cross-Clinical Commissioning Group referrals without special approval
Wider context from the report “9. That GPs cannot refer patients outside their Clinical Commissioning Group area without special permission/approval by the same . In order to do so, a ‘special case’ must be argued . This potentially limits patient (and practitioner) accessibility 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 of contemporaneous record keeping to support clinical recollections
Wider context from the report “5. That the GP’s recollection of events was not supported by contemporaneous record keeping , thus calling into question accuracy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to use recognised assessment tools in clinical evaluation
Wider context from the report “6. That the GP did not use a recognised assessment tool, as an adjunct or otherwise, in his clinical evaluation of the deceased . He felt that they were ineffective and of little, if any, value.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to assess medication appropriateness in light of patients’ mental health history
Wider context from the report “2. That the GP did not consider the appropriateness of the medication prescribed, particularly in light of the patient’s past mental health history - preferring to rely upon the presumed, anecdotal preferences of the community psychiatrists.
” 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 Enable mental health patients to choose any clinically appropriate provider for their first outpatient appointment, subject to stated exemptions.
Verbatim wording from the response “You raise a concern that GPs were unable to refer patients outside their Clinical Commissioning Group area without special permission/approval by the CCG and that this potentially limits patient (and practitioner) accessibility and treatment. I can advise that this is no longer the case. From 1 April 2014 patients with a mental health condition have had the same legal rights as physical health patients at first outpatient appointment to choose the provider that will deliver their care. The GP, or other referring healthcare professional, remains responsible for determining the clinically appropriate treatment to meet patients’ needs.” Source location 2014-0126-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 Concerns about the GP’s decisions and actions should be addressed by Pennine Care NHS Trust and York House Surgery.
Verbatim wording from the response “Many of the issues you raise concern the decisions and actions taken by the GP who diagnosed and treated Mr Chatburn. I note that you have sent your report to the Pennine Care NHS Trust and the York House Surgery and I would expect them to properly address these concerns.” Source location 2014-0126-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’s Performers Screening Group will determine whether specific action is needed regarding the GP’s clinical behaviour.
Verbatim wording from the response “My officials have consulted NHS England, as the main commissioner of primary care services, about your report. NHS England has advised that the GP’s clinical behaviour will be discussed at their next Performers Screening Group (PSG). The PSG will then determine if any specific actions need to be taken.” Source location 2014-0126-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 mental-health access arrangements, including single-point entry, triage and bureaucracy, are for the relevant CCG and Pennine Care Foundation Trust.
Verbatim wording from the response “Your remaining concerns relate to the current system for accessing mental health services in primary care. I am aware that a number of other inquests in the past have similarly focussed on the issue of a lack of clearly defined pathways for referral by GPs into mental health environments. The way in which these services are accessed is decided locally by the relevant NHS Trust. Thus your concerns surrounding the single point of entry, triage system and the evident bureaucracy are also more appropriately dealt with by the Clinical Commissioning Group (CCG) and Pennine Care Foundation Trust (FT). I am aware that the CCG is preparing its response in conjunction with both ████████ (Medical Director for the Greater Manchester Area Team) and Pennine Care.” Source location 2014-0126-Response-by-Department-of-Health
Open published response
Concerns raised 1 Lack of national guidance on the role of interpreters during labour, particularly in theatre View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrei Ciprian Matei · 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
Andrei Ciprian Matei was born following an emergency caesarean section and died aged 65 minutes after suffering progressive intrapartum hypoxia. The report identified concerns about the timing and method of delivery, failure to respond to abnormal fetal monitoring and obtain a further fetal blood sample, and the lack of national guidance on interpreters during labour and in theatre.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on the role of interpreters during labour, particularly in theatre
Wider context from the report “(1) There was no national guidance on the role of interpreters during labour in particular when the interpreter is required in theatre.
” 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 Bring concerns about interpreter roles during labour and in theatre to NICE for future consideration.
Verbatim wording from the response “Although the guidance I have detailed does not, and in my view could not reasonably specify the exact roles of interpreters during labour or in theatre, NICE may wish to consider a review of their current guidelines in this respect. I will ensure that the matters you raise are brought to their attention for future consideration.” Source location 2014-0089-Response
Open published response
Concerns raised 1 Failure to undertake rectal biopsy for diagnosis of Hirschsprung’s disease View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nathan Douthwaite · 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
Nathan Douthwaite had a long history of severe constipation requiring repeated hospital admissions and died after emergency admission in December 2010. Autopsy found massive megacolon with abdominal compartment syndrome and a perforated caecum, with Hirschsprung’s disease recorded as an underlying cause. The report raised concerns that a rectal biopsy might have diagnosed Hirschsprung’s disease and identified a need to review relevant guidelines and clinical practices.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake rectal biopsy for diagnosis of Hirschsprung’s disease
Wider context from the report “It is likely that if Nathan had undergone a rectal biopsy, Hirschsprung’s disease would have been diagnosed with the opportunity then being available for the appropriate treatment and thus I consider
(1) That NICE undertake a review of its guidelines in this regard
(2) That Count Durham and Darlington NHS Trust does review its own practices and procedures in avoidance of a NICE review and
(3) The Department of Health be aware of the circumstances of this case so that it can consider whether guidance should be issued in this regard pending the NICE review.
” 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 patient did not meet NICE criteria for rectal biopsy, so the absence of a biopsy did not indicate a departure from applicable guidance.
Verbatim wording from the response “method of diagnosis for Hirschsprung’s disease. No rectal biopsy was ever performed on Mr Douthwaite as he did not meet the criteria for Hirschsprung’s. Even under NICE’s guidelines on constipation, published in May 2010, Mr Douthwaite’s condition did not meet the criteria for rectal biopsy.” Source location 2014-0084-Response-by-Department-of-Health
Open published response
Concerns raised 3 Risk of chloroquine misuse View source Failure to regulate chloroquine View source Failure to ensure safe availability of chloroquine 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
Victoria Meppen-Walter · 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
Victoria Meppen-Walter underwent a dermatological procedure in September 2011 and subsequently experienced constant pain, scarring, social withdrawal and declining mental health. She researched assisted suicide and was later found deceased at her home with a do-not-resuscitate note and white powder residue; the inquest concluded that she had taken her own life, with chloroquine toxicity recorded as the medical cause of death. The principal concerns were the availability and regulation of chloroquine and the risk of associated misuse.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Risk of chloroquine misuse
Wider context from the report “1) The availability and regulation of chloroquine
&
2) The risk of associated misuse
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 chloroquine
Wider context from the report “1) The availability and regulation of chloroquine
&
2) The risk of associated misuse
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 safe availability of chloroquine
Wider context from the report “1) The availability and regulation of chloroquine
&
2) The risk of associated misuse
” Open source report
25 Feb 2014 Arthur Brockett-Deakins · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 8 Inadequate governance and oversight of private midwifery-led services across the mixed health economy View source Insufficient CTG interpretation training and competence View source Inconsistent thresholds for review and intervention between private and NHS maternity care View source Maternal pulse being displayed as fetal heart rate on CTG machines View source Unsafe staffing and shift arrangements for private midwifery services View source Failure to document and risk-assess private midwifery-led service arrangements View source Failure to escalate abnormal CTG findings appropriately in slow second-stage labour View source Insufficient specialist and interdisciplinary support for private midwifery-led services 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
Arthur Brockett-Deakins · 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
Arthur Brockett-Deakins was born in poor condition on 16 December 2007 after complications during labour and suffered severe disabilities resulting from acute profound perinatal hypoxic-ischaemic encephalopathy. He died at home on 18 October 2011 from respiratory problems. The report identified concerns about failure to escalate an abnormal CTG, administration and monitoring of Syntocinon, CTG interpretation and display of the maternal heart rate, and the organisation and support of a private midwifery-led service.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate governance and oversight of private midwifery-led services across the mixed health economy
Wider context from the report “4. Models of private midwifery led services for low risk pregnancy: The private midwifery caseload for low risk pregnancies was managed by a pair of midwives who set up the service to provide continuity of care. The midwife service that was operating when ████████ was pregnant was not adequately documented. No job description was seen by the court and the referral and operational arrangements were discussed, but no documentation was brought to the court. There was no evidence of risk assessment. Although NHS employees were required to be self sufficient in terms of annual leave and sickness cover, on call arrangements and use of NHS personnel except in emergencies. They did not at the outset have a link obstetrician. This led to fear of burn out, a sense of isolation and lack of support and collegiality.
When they transferred babies to the Hospital Birthing Centre, they were expected to refer to a duty obstetric consultant, access to whom was described as variable. The midwife in charge of the NHS unit agreed that she provided a different threshold of care to private and NHS mothers and was reluctant to intervene or review the care plan for augmentation of labour, which she would have done in an NHS patient. The midwives expected her to be involved but did not ask her. In the event no peer senior midwife or obstetrician saw ████████ which was necessary. The reasons for non referral were complex and were not because the midwives thought they could not refer. Misjudgements were made which in part were caused by a 15 hour shift with only a 40 minute break. This would not occur in contexts where there was normal NHS management of staff, but this arrangement continued apparently unknown to the NHS Trust management. The service is no longer operational, the Trust reporting that it was discontinued for economic reasons.
Expert advice considered that the model of service created a risk of deaths, although it was not found to have directly done so in this case. Dr ████████ reported that there were similar units operating elsewhere in the country and that the lessons from the difficulties in operating this one should be disseminated to other such units. The expert midwife, Ms ████████ was particularly concerned about adequate support and Dr. ████████ was particularly concerned about the isolation and professional culture and lack of interdisciplinary peer discussion, in the context of increasingly risks in obstetric and midwifery practice.
The Trust head midwife reported that she expected that the matter would now be dealt with robustly by the statutory supervision system. No evidence was heard about whether this was now effective in this regard , nor how influence and information could be brought to bear on those setting up or managing such midwife led services. It was further reported that not all midwives are members of the College that runs that supervision and that midwives are not necessarily practising within the NHS. Thus is it was not clear how the risks are best identified and managed across a complex mixed health economy , which is why the Secretary of State is an addressee of my report.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 CTG interpretation training and competence
Wider context from the report “2. Training of one midwife in CTG interpretation: Both midwives underwent voluntary further training and supervision, including an expert workshop on CTG interpretation. Both accepted that a number of errors had been made by them and applied the learning to their current practice. However even in retrospect, one of the midwives could not accept that the early CTG trace was pathological , as held by both expert obstetrician and midwife. Although she would refer now, there is doubt about the urgency . She said in court it would be within half an hour but also that 40 minutes was needed to see if it was abnormal. The expert midwife said that she needed further training on CTG interpretation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistent thresholds for review and intervention between private and NHS maternity care
Wider context from the report “4. Models of private midwifery led services for low risk pregnancy: The private midwifery caseload for low risk pregnancies was managed by a pair of midwives who set up the service to provide continuity of care. The midwife service that was operating when ████████ was pregnant was not adequately documented. No job description was seen by the court and the referral and operational arrangements were discussed, but no documentation was brought to the court. There was no evidence of risk assessment. Although NHS employees were required to be self sufficient in terms of annual leave and sickness cover, on call arrangements and use of NHS personnel except in emergencies. They did not at the outset have a link obstetrician. This led to fear of burn out, a sense of isolation and lack of support and collegiality.
When they transferred babies to the Hospital Birthing Centre, they were expected to refer to a duty obstetric consultant, access to whom was described as variable. The midwife in charge of the NHS unit agreed that she provided a different threshold of care to private and NHS mothers and was reluctant to intervene or review the care plan for augmentation of labour , which she would have done in an NHS patient. The midwives expected her to be involved but did not ask her. In the event no peer senior midwife or obstetrician saw ████████ which was necessary . The reasons for non referral were complex and were not because the midwives thought they could not refer. Misjudgements were made which in part were caused by a 15 hour shift with only a 40 minute break. This would not occur in contexts where there was normal NHS management of staff, but this arrangement continued apparently unknown to the NHS Trust management. The service is no longer operational, the Trust reporting that it was discontinued for economic reasons.
Expert advice considered that the model of service created a risk of deaths, although it was not found to have directly done so in this case. Dr ████████ reported that there were similar units operating elsewhere in the country and that the lessons from the difficulties in operating this one should be disseminated to other such units. The expert midwife, Ms ████████ was particularly concerned about adequate support and Dr. ████████ was particularly concerned about the isolation and professional culture and lack of interdisciplinary peer discussion, in the context of increasingly risks in obstetric and midwifery practice.
The Trust head midwife reported that she expected that the matter would now be dealt with robustly by the statutory supervision system. No evidence was heard about whether this was now effective in this regard, nor how influence and information could be brought to bear on those setting up or managing such midwife led services. It was further reported that not all midwives are members of the College that runs that supervision and that midwives are not necessarily practising within the NHS. Thus is it was not clear how the risks are best identified and managed across a complex mixed health economy, which is why the Secretary of State is an addressee of my report.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Maternal pulse being displayed as fetal heart rate on CTG machines
Wider context from the report “3. Display of MHR as FHR on CTGs: Ms ████████ explained that if the foetus moves out of the range of the ultrasound field or the baby has sadly died, the ultrasound transducer may then pick up the maternal pulse from the aorta, iliac or uterine artery and it is displayed as the FHR and can show reactivity and variability due to MHR changes and muscle contractions can be difficult to distinguish from the FHR. It is known that the rate can be doubled or halved .
The only explanation that both expert midwife and expert obstetrician could reach for the unusual CTG trace after 1pm, in the context of the state of the baby at birth, was that the maternal pulse rate was masquerading as the FHR but it had been multiplied by 1.5 . The CTG machine was not the type that is known rarely to multiply by 2 and the phenomenon of a multiplication by a factor other than 2, being unknown to both experts in their distinguished careers. Evidence was not heard from the manufacturer or the product's regulatory authority. The inquest heard that new CTG machines incorporate maternal ECG or pulse oximetry, which alerts staff to investigate when MHR and FHR appear the same. But it also heard that it will take some time before all old machines are replaced . It needs to be established if multiplying by 1.5 is a possible functional feature of some machines and if so whether either it can be designed away or whether dissemination or guidance or an action by the regulatory authority is needed to prevent it leading to a fatality or child disability.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unsafe staffing and shift arrangements for private midwifery services
Wider context from the report “4. Models of private midwifery led services for low risk pregnancy: The private midwifery caseload for low risk pregnancies was managed by a pair of midwives who set up the service to provide continuity of care. The midwife service that was operating when ████████ was pregnant was not adequately documented. No job description was seen by the court and the referral and operational arrangements were discussed, but no documentation was brought to the court. There was no evidence of risk assessment. Although NHS employees were required to be self sufficient in terms of annual leave and sickness cover, on call arrangements and use of NHS personnel except in emergencies. They did not at the outset have a link obstetrician. This led to fear of burn out, a sense of isolation and lack of support and collegiality.
When they transferred babies to the Hospital Birthing Centre, they were expected to refer to a duty obstetric consultant, access to whom was described as variable. The midwife in charge of the NHS unit agreed that she provided a different threshold of care to private and NHS mothers and was reluctant to intervene or review the care plan for augmentation of labour, which she would have done in an NHS patient. The midwives expected her to be involved but did not ask her. In the event no peer senior midwife or obstetrician saw ████████ which was necessary. The reasons for non referral were complex and were not because the midwives thought they could not refer. Misjudgements were made which in part were caused by a 15 hour shift with only a 40 minute break . This would not occur in contexts where there was normal NHS management of staff, but this arrangement continued apparently unknown to the NHS Trust management. The service is no longer operational, the Trust reporting that it was discontinued for economic reasons.
Expert advice considered that the model of service created a risk of deaths, although it was not found to have directly done so in this case. Dr ████████ reported that there were similar units operating elsewhere in the country and that the lessons from the difficulties in operating this one should be disseminated to other such units. The expert midwife, Ms ████████ was particularly concerned about adequate support and Dr. ████████ was particularly concerned about the isolation and professional culture and lack of interdisciplinary peer discussion, in the context of increasingly risks in obstetric and midwifery practice.
The Trust head midwife reported that she expected that the matter would now be dealt with robustly by the statutory supervision system. No evidence was heard about whether this was now effective in this regard, nor how influence and information could be brought to bear on those setting up or managing such midwife led services. It was further reported that not all midwives are members of the College that runs that supervision and that midwives are not necessarily practising within the NHS. Thus is it was not clear how the risks are best identified and managed across a complex mixed health economy, which is why the Secretary of State is an addressee of my report.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to document and risk-assess private midwifery-led service arrangements
Wider context from the report “4. Models of private midwifery led services for low risk pregnancy: The private midwifery caseload for low risk pregnancies was managed by a pair of midwives who set up the service to provide continuity of care. The midwife service that was operating when ████████ was pregnant was not adequately documented . No job description was seen by the court and the referral and operational arrangements were discussed, but no documentation was brought to the court . There was no evidence of risk assessment . Although NHS employees were required to be self sufficient in terms of annual leave and sickness cover, on call arrangements and use of NHS personnel except in emergencies. They did not at the outset have a link obstetrician. This led to fear of burn out, a sense of isolation and lack of support and collegiality.
When they transferred babies to the Hospital Birthing Centre, they were expected to refer to a duty obstetric consultant, access to whom was described as variable. The midwife in charge of the NHS unit agreed that she provided a different threshold of care to private and NHS mothers and was reluctant to intervene or review the care plan for augmentation of labour, which she would have done in an NHS patient. The midwives expected her to be involved but did not ask her. In the event no peer senior midwife or obstetrician saw ████████ which was necessary. The reasons for non referral were complex and were not because the midwives thought they could not refer. Misjudgements were made which in part were caused by a 15 hour shift with only a 40 minute break. This would not occur in contexts where there was normal NHS management of staff, but this arrangement continued apparently unknown to the NHS Trust management. The service is no longer operational, the Trust reporting that it was discontinued for economic reasons.
Expert advice considered that the model of service created a risk of deaths, although it was not found to have directly done so in this case. Dr ████████ reported that there were similar units operating elsewhere in the country and that the lessons from the difficulties in operating this one should be disseminated to other such units. The expert midwife, Ms ████████ was particularly concerned about adequate support and Dr. ████████ was particularly concerned about the isolation and professional culture and lack of interdisciplinary peer discussion, in the context of increasingly risks in obstetric and midwifery practice.
The Trust head midwife reported that she expected that the matter would now be dealt with robustly by the statutory supervision system. No evidence was heard about whether this was now effective in this regard, nor how influence and information could be brought to bear on those setting up or managing such midwife led services. It was further reported that not all midwives are members of the College that runs that supervision and that midwives are not necessarily practising within the NHS. Thus is it was not clear how the risks are best identified and managed across a complex mixed health economy, which is why the Secretary of State is an addressee of my report.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 escalate abnormal CTG findings appropriately in slow second-stage labour
Wider context from the report “1. When to escalate concerns about a CTG: With regard to not escalating an abnormal CTG that ran for about half an hour after augmentation of labour, reliance was placed by midwives on a clause of NICE Clinical Guidelines, Intrapartum Care, 2007, which advises that a 40 minutes trace should be studied before concluding if it is abnormal. Expert evidence from Dr ████████ and Ms ████████ suggested that this guidance was appropriate in the first stage of labour, but not in the context in this case, namely a slow second stage .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 specialist and interdisciplinary support for private midwifery-led services
Wider context from the report “4. Models of private midwifery led services for low risk pregnancy: The private midwifery caseload for low risk pregnancies was managed by a pair of midwives who set up the service to provide continuity of care. The midwife service that was operating when ████████ was pregnant was not adequately documented. No job description was seen by the court and the referral and operational arrangements were discussed, but no documentation was brought to the court. There was no evidence of risk assessment. Although NHS employees were required to be self sufficient in terms of annual leave and sickness cover, on call arrangements and use of NHS personnel except in emergencies. They did not at the outset have a link obstetrician . This led to fear of burn out, a sense of isolation and lack of support and collegiality.
When they transferred babies to the Hospital Birthing Centre, they were expected to refer to a duty obstetric consultant, access to whom was described as variable . The midwife in charge of the NHS unit agreed that she provided a different threshold of care to private and NHS mothers and was reluctant to intervene or review the care plan for augmentation of labour, which she would have done in an NHS patient. The midwives expected her to be involved but did not ask her. In the event no peer senior midwife or obstetrician saw ████████ which was necessary. The reasons for non referral were complex and were not because the midwives thought they could not refer. Misjudgements were made which in part were caused by a 15 hour shift with only a 40 minute break. This would not occur in contexts where there was normal NHS management of staff, but this arrangement continued apparently unknown to the NHS Trust management. The service is no longer operational, the Trust reporting that it was discontinued for economic reasons.
Expert advice considered that the model of service created a risk of deaths, although it was not found to have directly done so in this case. Dr ████████ reported that there were similar units operating elsewhere in the country and that the lessons from the difficulties in operating this one should be disseminated to other such units. The expert midwife, Ms ████████ was particularly concerned about adequate support and Dr. ████████ was particularly concerned about the isolation and professional culture and lack of interdisciplinary peer discussion , in the context of increasingly risks in obstetric and midwifery practice.
The Trust head midwife reported that she expected that the matter would now be dealt with robustly by the statutory supervision system. No evidence was heard about whether this was now effective in this regard, nor how influence and information could be brought to bear on those setting up or managing such midwife led services. It was further reported that not all midwives are members of the College that runs that supervision and that midwives are not necessarily practising within the NHS. Thus is it was not clear how the risks are best identified and managed across a complex mixed health economy, which is why the Secretary of State is an addressee of my report.
” 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 NMC is leading the national review of statutory midwifery supervision and is responsible for considering changes to that system.
Verbatim wording from the response “This disconnection between statutory supervision and performance management of midwives was of concern to the Parliamentary and Health Service Ombudsman in her report on maternity care in Morecambe Bay. She published her report - Midwifery supervision and regulation: recommendations for change - in December 2013 which has initiated a national review of statutory supervision which is being led by the NMC.” Source location 2014-0077-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The private midwifery-led service model was discontinued and no longer operates, so further action on that model is not indicated.
Verbatim wording from the response “As the NMC has already suggested, this is more appropriately addressed by my department. The model of midwifery provision described in this case was and is unacceptable and, for the reasons cited in the Regulation 28 Report, unsustainable. When this incident occurred in 2007 the Trust had a system of two midwives providing care to private patients who requested midwifery-led care. This system was discontinued in July 2010 and no longer operates. The model is not known to exist elsewhere in England.” Source location 2014-0077-Response-by-Department-of-Health
Open published response
25 Feb 2014 Lee Terence Curran · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 6 Failure to fully investigate prisoners’ reported episodes of loss of consciousness View source Failure to conduct NICE-compliant investigations of loss of consciousness View source Failure to make accurate and evidentially grounded entries in prisoners’ medical notes View source Failure to conduct clinical investigations of prisoners experiencing loss of consciousness View source Failure to take full account of family history when clinically investigating prisoners with possible high cholesterol View source Lack of doctors’ awareness of NICE guidelines for transient loss of consciousness View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lee Terence Curran · 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
Lee Terence Curran died on 3 May 2011 while in custody at Forest Bank Prison, with naturally occurring ischaemic heart disease identified as the prime cause of death. Before his death, he experienced multiple episodes of transient loss of consciousness that were not diagnosed, and concerns were raised that recommended investigations and follow-up were not provided. Further concerns included incomplete implementation of recommendations, potentially misleading medical-note entries, and inadequate awareness or application of relevant clinical guidelines.
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 fully investigate prisoners’ reported episodes of loss of consciousness
Wider context from the report “(3) Evidence given at the Inquest also revealed a need for the training of Doctors working in prisons in that Doctors who provided general practice sessions at the prison (and in the community) gave evidence that they were unaware of the NICE Guidelines for Transient Loss of Consciousness Management in Adults and Young People despite such episodes being common in a prison environment. Additionally evidence was given by a Doctor that efforts were not made to fully investigate Lee Terence Curran’s episodes of loss of consciousness because, the Doctor explained, it was common for prisoners to claim to have suffered losses of consciousness as a form of drug seeking behaviour .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct NICE-compliant investigations of loss of consciousness
Wider context from the report “(1) The Prisons and Probation Ombudsman investigated Lee Terence Curran’s death. At the conclusion of that investigation certain recommendations were made, two of which were as follows:
a. “The Head of Healthcare should ensure that healthcare staff take full account of family history when arranging clinical investigations for prisoners who report, or are observed to have possible signs of high cholesterol or hypertension”.
b. “The Head of Healthcare should develop a protocol that is NICE compliant for investigating episodes of loss of consciousness and should ensure that staff conduct clinical investigations of prisoners who experience such episodes.”
Both of these recommendations were accepted. However the evidence given at the Inquest in relation to the implementation of recommendation a. was that all prisoners coming to Forest Bank Prison undertake the reception screening process and any prisoner with any identified, or any sign of, hypertension is referred to the hypertension clinic. A full account of the prisoner’s family history is then taken at that clinic. There was no evidence that any action had been taken to address that part of the Ombudsman’s recommendation that related to prisoners (such as Lee Terence Curran) who reported or showed signs of having high cholesterol.
Likewise with recommendation b. The evidence given at the Inquest with regard to the implementation of that recommendation was that any individual who had a loss of consciousness would be automatically referred to a Doctor. That action does not encompass the whole of the Ombudsman’s recommendation. Particularly it does not ensure that investigations of episodes of loss of consciousness are NICE compliant nor does it ensure that staff conduct clinical investigations of prisoners who experience such episodes. It should be remembered here that Doctors saw Lee Terence Curran on five occasions following episodes of loss of consciousness and the NICE guidelines were not followed at any time .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to make accurate and evidentially grounded entries in prisoners’ medical notes
Wider context from the report “(2) Evidence given at the Inquest revealed a potential need for the training of Prison staff as to the manner in which they make entries in prisoners’ medical notes. Expressly, incorrect, and potentially misleading, information had been entered in Lee Terence Curran’s medical notes concerning the episodes of loss of consciousness that he experienced. For example a nurse described one such episode as a “petit mal seizure,” whilst evidence at the Inquest made it clear that such could not have been the case. In addition those attending information did not make the basis upon which they were entering that information clear, that is they entered information that indicated that they had witnessed an event when they had not .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct clinical investigations of prisoners experiencing loss of consciousness
Wider context from the report “(1) The Prisons and Probation Ombudsman investigated Lee Terence Curran’s death. At the conclusion of that investigation certain recommendations were made, two of which were as follows:
a. “The Head of Healthcare should ensure that healthcare staff take full account of family history when arranging clinical investigations for prisoners who report, or are observed to have possible signs of high cholesterol or hypertension”.
b. “The Head of Healthcare should develop a protocol that is NICE compliant for investigating episodes of loss of consciousness and should ensure that staff conduct clinical investigations of prisoners who experience such episodes.”
Both of these recommendations were accepted. However the evidence given at the Inquest in relation to the implementation of recommendation a. was that all prisoners coming to Forest Bank Prison undertake the reception screening process and any prisoner with any identified, or any sign of, hypertension is referred to the hypertension clinic. A full account of the prisoner’s family history is then taken at that clinic. There was no evidence that any action had been taken to address that part of the Ombudsman’s recommendation that related to prisoners (such as Lee Terence Curran) who reported or showed signs of having high cholesterol.
Likewise with recommendation b. The evidence given at the Inquest with regard to the implementation of that recommendation was that any individual who had a loss of consciousness would be automatically referred to a Doctor. That action does not encompass the whole of the Ombudsman’s recommendation. Particularly it does not ensure that investigations of episodes of loss of consciousness are NICE compliant nor does it ensure that staff conduct clinical investigations of prisoners who experience such episodes . It should be remembered here that Doctors saw Lee Terence Curran on five occasions following episodes of loss of consciousness and the NICE guidelines were not followed at any time.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to take full account of family history when clinically investigating prisoners with possible high cholesterol
Wider context from the report “(1) The Prisons and Probation Ombudsman investigated Lee Terence Curran’s death. At the conclusion of that investigation certain recommendations were made, two of which were as follows:
a. “The Head of Healthcare should ensure that healthcare staff take full account of family history when arranging clinical investigations for prisoners who report, or are observed to have possible signs of high cholesterol or hypertension”.
b. “The Head of Healthcare should develop a protocol that is NICE compliant for investigating episodes of loss of consciousness and should ensure that staff conduct clinical investigations of prisoners who experience such episodes.”
Both of these recommendations were accepted. However the evidence given at the Inquest in relation to the implementation of recommendation a. was that all prisoners coming to Forest Bank Prison undertake the reception screening process and any prisoner with any identified, or any sign of, hypertension is referred to the hypertension clinic. A full account of the prisoner’s family history is then taken at that clinic. There was no evidence that any action had been taken to address that part of the Ombudsman’s recommendation that related to prisoners (such as Lee Terence Curran) who reported or showed signs of having high cholesterol.
Likewise with recommendation b. The evidence given at the Inquest with regard to the implementation of that recommendation was that any individual who had a loss of consciousness would be automatically referred to a Doctor. That action does not encompass the whole of the Ombudsman’s recommendation. Particularly it does not ensure that investigations of episodes of loss of consciousness are NICE compliant nor does it ensure that staff conduct clinical investigations of prisoners who experience such episodes. It should be remembered here that Doctors saw Lee Terence Curran on five occasions following episodes of loss of consciousness and the NICE guidelines were not followed at any time.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of doctors’ awareness of NICE guidelines for transient loss of consciousness
Wider context from the report “(3) Evidence given at the Inquest also revealed a need for the training of Doctors working in prisons in that Doctors who provided general practice sessions at the prison (and in the community) gave evidence that they were unaware of the NICE Guidelines for Transient Loss of Consciousness Management in Adults and Young People despite such episodes being common in a prison environment . Additionally evidence was given by a Doctor that efforts were not made to fully investigate Lee Terence Curran’s episodes of loss of consciousness because, the Doctor explained, it was common for prisoners to claim to have suffered losses of consciousness as a form of drug seeking behaviour.
” Open source report
Concerns raised 1 Failure to automatically link fall height, age and anti-clotting medication use to an eight-minute ambulance response 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
Graham James Sutton · 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 10 July 2013, Graham James Sutton fell five feet from a ladder while cutting a hedge, struck his head on concrete, and later died after being taken to hospital and transferred to a Trauma Centre. The concern was that the London Ambulance Service did not automatically link the fall, his age over 50, and his use of the anti-clotting medication Clopidogrel to a response within eight minutes.
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 automatically link fall height, age and anti-clotting medication use to an eight-minute ambulance response
Wider context from the report “The fact that Mr Sutton had fallen as little as 5 feet, that he was over 50 years old and that he was taking anti-clotting medications, (Clopidogrel), were not linked automatically by the London Ambulance Service to result in a response within 8 minutes .
” Open source report
Concerns raised 2 Failure to comply with guidelines on citalopram repeat prescribing View source Delays in access to psychotherapy making it an unavailable alternative to anti-depressant medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lee Jay Bonsall · 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
Lee Jay Bonsall was found hanging from a bannister rail at his home on 3 March 2012, and the inquest recorded the medical cause of death as asphyxia by hanging, with intent unclear. Concerns related to citalopram being prescribed on repeat and the ten-month waiting time for psychotherapy.
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 comply with guidelines on citalopram repeat prescribing
Wider context from the report “(1) That citalopram was given on repeat prescription which is contrary to guidelines . It may well be that awareness of these guidelines needs to be raised to ensure that GPs are aware that citalopram should not be given on
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 access to psychotherapy making it an unavailable alternative to anti-depressant medication
Wider context from the report “(2) The ten month waiting times for psychotherapy effectively means that this is not a viable alternative to anti-depressant medication and it might well be that a review of these waiting times is appropriate.
” 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 revised mental-health access and waiting-time standards to improve parity with physical-health services.
Verbatim wording from the response “The Department and NHS England are committed to ending this imbalance. We believe that it is vital to develop and implement new access and waiting time standards to have true parity of esteem. We are committed to providing access to services and waiting times on a par with physical health.” Source location 2014-0044-Response-by-Department-of-Health-1
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 Implement revised mental-health access and waiting-time standards through a phased programme beginning in April 2015.
Verbatim wording from the response “The Department and NHS England are committed to ending this imbalance. We believe that it is vital to develop and implement new access and waiting time standards to have true parity of esteem. We are committed to providing access to services and waiting times on a par with physical health.” Source location 2014-0044-Response-by-Department-of-Health-1
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 Prescribing responsibility rests with the clinically responsible prescriber, while local primary care organisations must ensure adequate controls.
Verbatim wording from the response “Responsibility for prescribing, including repeat prescribing, rests with the prescriber who has clinical responsibility for that particular aspect of a patient’s care. This includes considering the suitability of prescribing a particular medicine for a particular patient in light of individual circumstances. In England it is the responsibility of local primary care organisations to ensure that adequate controls are in place. They may therefore issue advice to GPs on repeat prescribing mechanisms.” Source location 2014-0044-Response-by-Department-of-Health-1
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 Further investigation of the cited prescribing guidelines depends on receiving identifying information and confirming that the matter falls within remit.
Verbatim wording from the response “Although your letter mentions guidelines, we cannot therefore establish exactly what you are referring to. I would look into this matter further if you could supply the information and if it falls within my remit.” Source location 2014-0044-Response-by-Department-of-Health-1
Open published response
30 Jan 2014 Tallulah Mary Scarlett WILSON · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to include digital lives basic training and audit in standard induction training View source Lack of healthcare professionals’ understanding of young people’s online lives View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tallulah Mary Scarlett WILSON · 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
Tallulah Wilson, a fifteen-year-old schoolgirl, died after jumping in front of a train and taking her own life. The report highlighted concerns about healthcare professionals’ limited understanding of young people’s online lives and the need for research, improved clinical practice, risk-assessment refinement and relevant training.
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 include digital lives basic training and audit in standard induction training
Wider context from the report “Digital lives basic training and audit is already available, but is not part of standard induction training to raise awareness for all in psychiatric and psychological fields, let alone for all doctors .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of healthcare professionals’ understanding of young people’s online lives
Wider context from the report “Although Tallulah was treated by a number of healthcare professionals, and her mother was extremely concerned about her wellbeing, no person who gave evidence felt that, at the time they were looking after Tallulah, they had a good enough understanding of the evolving way that the internet is used by young people , most particularly in terms of the online life that is quite separate from, but sometimes seems to be used to try to validate, the rest of life .
” 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 Fund and undertake research on internet use in relation to suicidal behaviour to inform prevention advice and identify potential interventions.
Verbatim wording from the response “I recognise the increasing importance of the role of media and in particular social media in the lives of young people. The first annual report on England’s cross-government suicide prevention strategy, Preventing Suicide in England: One Year On was published on 17 January and noted that the Policy Research Programme is investing £1.5 million into six projects, one of which will explore the use of the internet in relation to suicidal behaviour and identifying priorities for prevention.” Source location 2014-0047-Response-by-Department-of-Health
Open published response
27 Jan 2014 Judith Lesley Marshall · Prevention of Future Deaths report York City
View report summary
Concerns raised 7 Uncertainty about availability of prescription-reading software alerts for drug identity or amount errors View source Absence of a central database of prescription errors View source Failure of colleague checking to prevent dispensing medication errors View source Lack of mandatory end-of-day reconciliation of prescription-only drugs dispensed against prescriptions View source Lack of policing of internal pharmacy error records View source Lack of mandatory read-back procedures for dispensing details View source Lack of central monitoring and trend analysis of prescription errors View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Judith Lesley 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
Judith Lesley Marshall was prescribed morphine sulphate 10mg twice daily, but a pharmacy dispensed 60mg capsules. She took the capsules as prescribed and was found dead on 30 September 2009; the inquest recorded bronchopneumonia and the effects of morphine, with a conclusion of accidental death. The principal concerns were pharmacy dispensing errors, the adequacy of checking and monitoring systems, and the absence of central monitoring of prescription errors.
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 Uncertainty about availability of prescription-reading software alerts for drug identity or amount errors
Wider context from the report “(3) It is not clear whether there is any software , obtainable from the Department of Health or elsewhere, that could read prescriptions and raise an alert if the label sought to be created or if the drug sought to be dispensed is wrong in identity or amount . This would be of particular significance when a high risk drug is dispensed or when a drug is dispensed in an unusual quantity, dosage or form.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of a central database of prescription errors
Wider context from the report “(6) There is evidently no central database of all prescription errors so there can be no central monitoring of such errors and no means of determining trends or particular repeat errors.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 colleague checking to prevent dispensing medication errors
Wider context from the report “(2) Despite a system of checking by a colleague it is apparent that there can be a mistake in dispensing medication which in this case was a controlled opiate drug. The consequences were fatal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory end-of-day reconciliation of prescription-only drugs dispensed against prescriptions
Wider context from the report “(5) A mandatory check, by a suitably qualified pharmacist or by a third party, at the end of the day after cashing up on the till, of records of each (prescription only) drug dispensed against the prescription would be a further precaution against a repetition of these circumstances.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of policing of internal pharmacy error records
Wider context from the report “(1) The Pharmacy’s Errors Book shows a number of drug errors (including higher or lower dose tablets and three wrong drugs) over a number of years. It is not clear whether and to what extent such internal records are policed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory read-back procedures for dispensing details
Wider context from the report “(4) Mandatory procedures requiring a ‘read-back’ of the drug, its dosage, its frequency of administration and its total quantity may prevent such dispensing errors . In so far as the error in this case can be attributable to ‘Human Error’ it is concluded that the dispensing pharmacist focused on the figure of 60 and incorrectly attributed that to the dosage as well as to the number of capsules.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 central monitoring and trend analysis of prescription errors
Wider context from the report “(6) There is evidently no central database of all prescription errors so there can be no central monitoring of such errors and no means of determining trends or particular repeat errors .
” 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 NHS England is responsible for commissioning pharmaceutical services and has addressed the concerns in its detailed response.
Verbatim wording from the response “As Secretary of State for Health, I am responsible for setting national priorities, monitoring the whole system’s performance and supporting the integrity of the system to protect the best interests of patients, the public and the taxpayer. Since 1 April 2013, most day to day decisions are taken by NHS England. NHS England is responsible for commissioning primary care services, including pharmaceutical services.” Source location 2014-0039-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