Concerns raised 3 Lack of consultant supervision of emergency paediatric admissions by on-call trainees or sub-consultant paediatric doctors View source Lack of independent consultant assessment of paediatric admissions View source Lack of national guidelines for assessment and investigation of headaches in children 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
Lucy Maria GOULDING · 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
Lucy Goulding was admitted to hospital on 26 June 2013 with worsening headaches, later collapsed and suffered a cardiorespiratory arrest, and was confirmed dead on 27 June 2013 after emergency treatment for a brain tumour. The principal concerns were inadequate consultant supervision and independent assessment of paediatric admissions, and the lack of national guidelines for assessing and investigating headaches in children.
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 consultant supervision of emergency paediatric admissions by on-call trainees or sub-consultant paediatric doctors
Wider context from the report “1. Lack of consultant supervision of on-call paediatric trainees or sub-consultant paediatric doctors admitting paediatric patients as an emergency into Worthing Hospital
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of independent consultant assessment of paediatric admissions
Wider context from the report “2. Lack of independent consultant assessment of paediatric admissions into Worthing Hospital in and 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 Lack of national guidelines for assessment and investigation of headaches in children
Wider context from the report “3. Lack of national guidelines for assessment and investigation of headaches in children
” Open source report
Concerns raised 1 Failure to ensure that advice about clinical care for patients with special clinical requirements reaches all treating clinicians View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mone Jahni Karl White · 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
Mone Jahni Karl White, who had dilated cardiomyopathy and recurrent illness requiring hospital treatment, was admitted to Northwick Park Hospital on 5 July 2012 and became unresponsive on 7 July 2012 despite treatment attempts. The treating doctors had not seen specialist guidance about Mone’s clinical requirements, and the report raised concern about ensuring such advice is brought to the attention of all treating clinicians.
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 that advice about clinical care for patients with special clinical requirements reaches all treating clinicians
Wider context from the report “(1) The development of a flag system for patients, under the care of specialist hospitals, with special clinical requirements to ensure that advice about clinical care is brought to the attention of all treating clinicians .
” 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 Developing a specialist-patient flag system is a local matter; the NHS Trust must ensure relevant information is routinely accessed and acted upon.
Verbatim wording from the response “With regard to developing a flag system in specialist hospitals to ensure that advice about clinical care is brought to the attention of all treating clinicians, I consider that” Source location 2014-0031-Response
Open published response
Concerns raised 3 Unavailability of specially trained nursing staff for hospital patients with substance misuse View source Unavailability of a dedicated substance misuse team in police custody suites View source Failure of SERCO handcuffing policy to align with ACPO guidance for seriously ill detainees View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Wayne Spencer Malcolm Broad · 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
Wayne Spencer Malcolm Broad was arrested while under the influence of alcohol and became unwell during transfer between police custody, court and hospital. He later developed delirium tremens, collapsed despite resuscitation and died after suffering a hypoxic injury. Concerns included the lack of a dedicated substance misuse team in police custody, the need for alignment of handcuffing procedures with guidance for seriously ill detainees, and the availability of specially trained nursing staff for patients with substance 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 Unavailability of specially trained nursing staff for hospital patients with substance misuse
Wider context from the report “(3) Specially trained nursing staff should be available at hospitals for dealing with patients with substance 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 Unavailability of a dedicated substance misuse team in police custody suites
Wider context from the report “(1) That was no dedicated substance misuse team available to look after Mr Broad when he was in the custody suite at Hatfield Police Station , as there would have been had Mr Broad been detained in prison.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 SERCO handcuffing policy to align with ACPO guidance for seriously ill detainees
Wider context from the report “(2) Police are required to make risk assessments and have requirements when dealing with the handcuffing of seriously ill detainees. There should be alignment with particular regard to those who are seriously ill and in general SERCO policy should come into alignment with ACPO guidance on the use of handcuffs .
” 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 presence of a specialist substance-misuse nurse would not have produced a different outcome in this case.
Verbatim wording from the response “In this case the patient was admitted with a life threatening condition needing emergency intervention. The effect of long term alcohol abuse and associated complications led to the need for emergency resuscitation. The role of a specialist substance misuse nurse would in contrast involve making an assessment of the patient and determining the best options in terms of referral or appropriate care pathway. In this case I do not feel that the presence of a specialist substance misuse nurse would have led to a different outcome for Mr Broad.” Source location 2014-0020-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police risk assessments and handcuffing protocols are outside the Department of Health’s remit.
Verbatim wording from the response “• Police are required to make risk assessments and have protocols for dealing with the handcuffing of seriously ill detainees. SERCO policy should align with ACPO guidance on the use of handcuffs” Source location 2014-0020-Response
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 Routine specialist substance-misuse nurses are unnecessary because registered nurses, multidisciplinary teams and established care pathways provide appropriate care.
Verbatim wording from the response “You suggest in your third point that specially trained nursing staff should be available in hospitals for dealing with patients with substance misuse. I do not however consider that such specialist nurses should routinely be available in all hospitals.” Source location 2014-0020-Response
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 commissioners are responsible for determining specialist substance-misuse nurse provision according to assessed local need and resources.
Verbatim wording from the response “However, the provision of specialist substance misuse nurses is a matter for local commissioners to determine based on an assessment of local needs. There may be some hospitals where the resources required to make this facility available would be justified but, where there are very few presentations from patients with substance misuse problems, providing such a service might not be the most effective use of available resources.” Source location 2014-0020-Response
Open published response
16 Jan 2014 May Stokoe and James Henderson Stokoe · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 2 Failure to formally consult carers or partners in mental health welfare assessments View source Failure to avoid discounting domestic abuse involving elderly people in mental health service assessments 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
May Stokoe and James Henderson Stokoe · 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 1 May 2013, May Stokoe was fatally attacked with a knife and James Henderson Stokoe inflicted fatal knife injuries on himself. The report raised concerns about the assessment and involvement of carers or partners in mental health services, including whether their information could better inform risk assessments and whether domestic abuse involving older people might be missed.
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 formally consult carers or partners in mental health welfare assessments
Wider context from the report “I was also concerned about the possibility that carers or partners of individuals who are subject to the provision of Mental Health Services are not formally consulted about the welfare of the patient/service user . Although I was satisfied that domestic abuse awareness was an integral part of training for Mental Health staff, the circumstances of the deaths of Mr and Mrs Stokoe did raise for me concerns that more formal involvement of a carer/partner may allow them to make disclosures which might better inform the assessment process . For example, information from them may corroborate or verify that being provided by the service user/patient. In my view carers/partners may be a very valuable source of information which may not necessarily be disclosed or volunteered by the service user or patient . Carers/partners should have more visibility to the Mental Health Services and domestic abuse involving the elderly cannot be discounted and matters should be approached with an open mind.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 avoid discounting domestic abuse involving elderly people in mental health service assessments
Wider context from the report “I was also concerned about the possibility that carers or partners of individuals who are subject to the provision of Mental Health Services are not formally consulted about the welfare of the patient/service user. Although I was satisfied that domestic abuse awareness was an integral part of training for Mental Health staff, the circumstances of the deaths of Mr and Mrs Stokoe did raise for me concerns that more formal involvement of a carer/partner may allow them to make disclosures which might better inform the assessment process. For example, information from them may corroborate or verify that being provided by the service user/patient. In my view carers/partners may be a very valuable source of information which may not necessarily be disclosed or volunteered by the service user or patient. Carers/partners should have more visibility to the Mental Health Services and domestic abuse involving the elderly cannot be discounted and matters should be approached with an open mind .
” Open source report
14 Jan 2014 Stephen Ellis · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of warfarin home management kits for high-risk patients after heart surgery 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 Ellis · 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 Ellis was admitted for heart surgery and subsequently received warfarin. After discharge, INR checks were reduced to weekly and his rising INR was apparently not properly noted; the principal concern was that high-risk patients undergoing heart surgery and subsequent warfarin treatment should be supplied with home monitoring kits.
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 warfarin home management kits for high-risk patients after heart surgery
Wider context from the report “I believe it would be good practice to supply warfarin home management kits to ‘high risk’ patients who have undergone heart surgery and are subsequently warfarinised . The cost of such kits would probably equate to, or be less than, the cost of hospital monitoring.
” Open source report
Concerns raised 12 Failure to secure mutual aid for bed watch cover View source Lack of clarity about responsibility for funding and payment of privately funded care and transfers View source Lack of clarity about the circumstances and means for arranging hospital transfers View source Unavailability of scales in all medical consulting rooms View source Lack of a system guiding privately funded transfers between hospitals View source Failure of medical records to clearly record information availability, entry timing and authorship View source Failure of doctors and nurses to routinely weigh patients View source Lack of designated ownership and control for complex hospital transfer arrangements View source Lack of policy or guidance for prison staff and health care providers managing complex privately funded transfers View source Delays and limitations in liaison and communication between prison and hospital health care staff View source Lack of clarity in rules governing prisoners’ entitlement to private health care View source Lack of a formal policy for situations involving privately funded prisoner health care and hospital transfers View source See 9 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
Zeeyad Hamadi · 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
Zeeyad Hamadi was a prisoner at HMP Frankland who became unwell, was diagnosed with Hodgkins Lymphoma, and deteriorated while arrangements were made to transfer him to a London hospital for private chemotherapy. Concerns included inadequate weighing and medical record keeping, limited communication between prison and hospital staff, unclear funding and transfer arrangements, and the absence of a system or responsible point of contact to manage the transfer, contributing to delay.
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 secure mutual aid for bed watch cover
Wider context from the report “(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance. There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded. There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented.
Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about responsibility for funding and payment of privately funded care and transfers
Wider context from the report “(3) There was limited liaison between health care staff in HMP Frankland and medical staff at UHND to monitor the deceased’s medical condition once he had left the prison. When a decision was made by the deceased to seek treatment in London on a private paying basis this information was not speedily communicated to those responsible for health care in HMP Frankland and contact was made by a hospital doctor with a duty governor at the prison who in turn had to refer to the health care manager. Confusion developed as to the basis of the proposed move to Bart’s from UHND; whether this was a prison to prison transfer or whether it was a relocation of the deceased from one hospital to another whilst remaining the responsibility of HMP Frankland. There was confusion over the funding arrangements for this proposal; whether the local NHS would be responsible for the medical treatment or the costs of transport, the form of such transport and/or the costs of bed watch. The brother of the deceased confirmed to different people at different times that he would undertake to be responsible for the costs incurred (subject to a challenge by Judicial review) and it took some time for the issues of funding to be identified before being addressed and resolved. There was a lack of clarity of understanding who would be responsible for what and when, so far as money was concerned and who would have the responsibility for payment in the first place prior to reimbursement by the deceased’s brother . There was no formal policy in place to deal with the situation. There was lack of clarity in the rules that were referred to in evidence as to how and when a convicted prisoner is entitled to private health care as opposed to a prisoner on remand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the circumstances and means for arranging hospital transfers
Wider context from the report “(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance . There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded. There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented.
Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 scales in all medical consulting rooms
Wider context from the report “(1) The evidence disclosed that the deceased had not been weighed at the times of medical appointments and a history of weight loss would have been a useful diagnostic tool. Not all medical consulting rooms at HMP Frankland had scales to do so and doctors/nurses did not routinely weigh patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a system guiding privately funded transfers between hospitals
Wider context from the report “(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance. There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded . There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented.
Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 medical records to clearly record information availability, entry timing and authorship
Wider context from the report “(2) It was accepted in evidence that the standard of record keeping in the patient’s medical notes was not as good as it could or should have been . There was lack of clarity as to when certain medical information (for example blood tests results) were available for interpretation by a doctor , by paper or electronic means, there was lack of clarity as from the computer printouts of medical records when entries were inputted into the system and were available for view, who was the author of the entry (as opposed to who inputted the data) .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 doctors and nurses to routinely weigh patients
Wider context from the report “(1) The evidence disclosed that the deceased had not been weighed at the times of medical appointments and a history of weight loss would have been a useful diagnostic tool. Not all medical consulting rooms at HMP Frankland had scales to do so and doctors/nurses did not routinely weigh patients .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of designated ownership and control for complex hospital transfer arrangements
Wider context from the report “(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance. There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded. There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented.
Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of policy or guidance for prison staff and health care providers managing complex privately funded transfers
Wider context from the report “(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance. There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded. There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented.
Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 and limitations in liaison and communication between prison and hospital health care staff
Wider context from the report “(3) There was limited liaison between health care staff in HMP Frankland and medical staff at UHND to monitor the deceased’s medical condition once he had left the prison . When a decision was made by the deceased to seek treatment in London on a private paying basis this information was not speedily communicated to those responsible for health care in HMP Frankland and contact was made by a hospital doctor with a duty governor at the prison who in turn had to refer to the health care manager. Confusion developed as to the basis of the proposed move to Bart’s from UHND; whether this was a prison to prison transfer or whether it was a relocation of the deceased from one hospital to another whilst remaining the responsibility of HMP Frankland. There was confusion over the funding arrangements for this proposal; whether the local NHS would be responsible for the medical treatment or the costs of transport, the form of such transport and/or the costs of bed watch. The brother of the deceased confirmed to different people at different times that he would undertake to be responsible for the costs incurred (subject to a challenge by Judicial review) and it took some time for the issues of funding to be identified before being addressed and resolved. There was a lack of clarity of understanding who would be responsible for what and when, so far as money was concerned and who would have the responsibility for payment in the first place prior to reimbursement by the deceased’s brother. There was no formal policy in place to deal with the situation. There was lack of clarity in the rules that were referred to in evidence as to how and when a convicted prisoner is entitled to private health care as opposed to a prisoner on remand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in rules governing prisoners’ entitlement to private health care
Wider context from the report “(3) There was limited liaison between health care staff in HMP Frankland and medical staff at UHND to monitor the deceased’s medical condition once he had left the prison. When a decision was made by the deceased to seek treatment in London on a private paying basis this information was not speedily communicated to those responsible for health care in HMP Frankland and contact was made by a hospital doctor with a duty governor at the prison who in turn had to refer to the health care manager. Confusion developed as to the basis of the proposed move to Bart’s from UHND; whether this was a prison to prison transfer or whether it was a relocation of the deceased from one hospital to another whilst remaining the responsibility of HMP Frankland. There was confusion over the funding arrangements for this proposal; whether the local NHS would be responsible for the medical treatment or the costs of transport, the form of such transport and/or the costs of bed watch. The brother of the deceased confirmed to different people at different times that he would undertake to be responsible for the costs incurred (subject to a challenge by Judicial review) and it took some time for the issues of funding to be identified before being addressed and resolved. There was a lack of clarity of understanding who would be responsible for what and when, so far as money was concerned and who would have the responsibility for payment in the first place prior to reimbursement by the deceased’s brother. There was no formal policy in place to deal with the situation. There was lack of clarity in the rules that were referred to in evidence as to how and when a convicted prisoner is entitled to private health care as opposed to a prisoner on remand .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 formal policy for situations involving privately funded prisoner health care and hospital transfers
Wider context from the report “(3) There was limited liaison between health care staff in HMP Frankland and medical staff at UHND to monitor the deceased’s medical condition once he had left the prison. When a decision was made by the deceased to seek treatment in London on a private paying basis this information was not speedily communicated to those responsible for health care in HMP Frankland and contact was made by a hospital doctor with a duty governor at the prison who in turn had to refer to the health care manager. Confusion developed as to the basis of the proposed move to Bart’s from UHND; whether this was a prison to prison transfer or whether it was a relocation of the deceased from one hospital to another whilst remaining the responsibility of HMP Frankland. There was confusion over the funding arrangements for this proposal; whether the local NHS would be responsible for the medical treatment or the costs of transport, the form of such transport and/or the costs of bed watch. The brother of the deceased confirmed to different people at different times that he would undertake to be responsible for the costs incurred (subject to a challenge by Judicial review) and it took some time for the issues of funding to be identified before being addressed and resolved. There was a lack of clarity of understanding who would be responsible for what and when, so far as money was concerned and who would have the responsibility for payment in the first place prior to reimbursement by the deceased’s brother. There was no formal policy in place to deal with the situation . There was lack of clarity in the rules that were referred to in evidence as to how and when a convicted prisoner is entitled to private health care as opposed to a prisoner on remand.
” 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 Consult with NOMS on prisoners’ access to private healthcare and transfers from NHS care.
Verbatim wording from the response “Officials have consulted with NOMS and with regard to the issue of whether a prisoner is entitled to use private healthcare, and what happens if they are using NHS services and wish to transfer to the private sector, I can confirm that it is very rare for a prisoner to seek private treatment. There are no national protocols currently in place by which a request for private treatment from a prisoner would be considered.” Source location 2014-0014-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record keeping, prison-hospital liaison, bed-watch security and prison ownership issues are not for the Department of Health to respond to.
Verbatim wording from the response “I consider that several of the issues you have raised regarding record keeping, liaison between prison and hospital medical staff, security issues such as bed-watch and ownership of the situation at the prison, are not for my Department to respond.” Source location 2014-0014-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 National Offender Management Service is expected to address record keeping, liaison, bed-watch security and ownership issues.
Verbatim wording from the response “I note that you have sent a copy of this Regulation 28 report to the National Offender Management Service (NOMS) and I would expect them to properly address these issues.” Source location 2014-0014-Response-by-Department-of-Health
Open published response
Concerns raised 1 Unavailability of a specialist diabetic nurse at the hospital over weekends View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Grace Mary Bates · 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
Grace Mary Bates died in hospital on 21 April 2013 from complications associated with poorly managed diabetic episodes. The report raised concern that no specialist diabetic nurse was available at the hospital over the weekend, during which her blood sugar management was poor.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a specialist diabetic nurse at the hospital over weekends
Wider context from the report “(1) That should be a specialist diabetic nurse available over the weekend at the 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 Local healthcare organisations are responsible for assessing needs and commissioning and delivering safe diabetes services, including appropriate nursing staff.
Verbatim wording from the response “Local organisations are best placed to assess the needs of their populations, and to commission and deliver high-quality, safe and comprehensive diabetes services; including appropriate nursing staff and I expect local healthcare organisations to do their utmost to deliver care against NICE standards as part of a general duty to ensure continuous improvement in quality.” Source location 2014-0007-Response-2
Open published response
17 Dec 2013 William Alfred Andrews · Prevention of Future Deaths report South Yorkshire (West)
View report summary
Concerns raised 4 Lack of a standard procedure for checking and counting syringe caps at the end of operations View source Failure to ensure that detachable syringe caps are visibly different in colour from the equipment View source Failure to implement recommended strategies to reduce recurrence of plastic obstruction incidents View source Failure to ensure operating staff are aware that bulb syringes are supplied with caps View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
William Alfred Andrews · 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
William Alfred Andrews, a 77-year-old man, underwent cardiac surgery and subsequently suffered repeated circulatory arrests after a bulb syringe cap entered and remained in his left ventricle. The cap was later removed during a second operation, but his condition deteriorated and he died. Concerns included the cap's lack of visibility, inadequate awareness of its presence, and the absence of a standard procedure to check and count syringe caps at the end of surgery.
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 standard procedure for checking and counting syringe caps at the end of operations
Wider context from the report “(1) If a simple precaution was taken in ensuring that the tip of a bulb syringe or similar was a different colour to the rest of the equipment then it is difficult to see how a surgeon could use a syringe with the tip still in place by error. As the attached photograph shows there is no significant difference between the syringe with the tip on or off.
(2) There is a further concern in respect of other information which is contained with the Trust’s SUI report as follows:
It is perhaps of some relevance that in 2001-2 a number of instances of items of anaesthetic airway equipment being blocked with extraneous pieces of plastic and causing harm to patients were the subject of a national police investigation (Operation Cordian). The police findings were examined by an Expert Group, which published a series of recommendations in 2004. Their conclusion was that there was no criminal intent but that the incidents had happened as a matter of chance. Strategies to reduce the chances of these events recurring were recommended. Recommendation 1 states “The MHRA should recommend to manufacturers and the relevant Standards Committees that ….. detachable caps (eg. On intravenous cannulae and giving sets) be manufactured in brightly coloured material, preferably red, to aid visibility”.
No action appears to have been taken in consequence of this.
(3) The SUI report goes on to indicate that none of the team undertaking the operation were aware that the bulb syringe came supplied with a cap. The previous brand used by the Trust was not supplied with a syringe cap. The current bulb syringes in use obviously do have a cap but this is normally removed by the scrub practitioner before the syringe is supplied to the operating surgeon. Thus there has been little opportunity for surgeons to appreciate that syringes now have caps. This underlines the importance of ensuring that such devices are manufactured with a brightly coloured cap, if one is to be used at all.
(4) There appears to be no standard procedure for checking for syringe caps (where used) at the end of the operation , such as there is with swabs. The evidence available to me suggests that items such as syringe caps are just discarded by the scrub practitioner without being retained for counting . Of course, the fact that some syringes are apparently manufactured with a cap and others without complicates the situation but is not actually a bar to counting the number of caps present at the outset of the operation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that detachable syringe caps are visibly different in colour from the equipment
Wider context from the report “(1) If a simple precaution was taken in ensuring that the tip of a bulb syringe or similar was a different colour to the rest of the equipment then it is difficult to see how a surgeon could use a syringe with the tip still in place by error. As the attached photograph shows there is no significant difference between the syringe with the tip on or off .
(2) There is a further concern in respect of other information which is contained with the Trust’s SUI report as follows:
It is perhaps of some relevance that in 2001-2 a number of instances of items of anaesthetic airway equipment being blocked with extraneous pieces of plastic and causing harm to patients were the subject of a national police investigation (Operation Cordian). The police findings were examined by an Expert Group, which published a series of recommendations in 2004. Their conclusion was that there was no criminal intent but that the incidents had happened as a matter of chance. Strategies to reduce the chances of these events recurring were recommended. Recommendation 1 states “The MHRA should recommend to manufacturers and the relevant Standards Committees that ….. detachable caps (eg. On intravenous cannulae and giving sets) be manufactured in brightly coloured material, preferably red, to aid visibility”.
No action appears to have been taken in consequence of this.
(3) The SUI report goes on to indicate that none of the team undertaking the operation were aware that the bulb syringe came supplied with a cap. The previous brand used by the Trust was not supplied with a syringe cap. The current bulb syringes in use obviously do have a cap but this is normally removed by the scrub practitioner before the syringe is supplied to the operating surgeon. Thus there has been little opportunity for surgeons to appreciate that syringes now have caps. This underlines the importance of ensuring that such devices are manufactured with a brightly coloured cap, if one is to be used at all.
(4) There appears to be no standard procedure for checking for syringe caps (where used) at the end of the operation, such as there is with swabs. The evidence available to me suggests that items such as syringe caps are just discarded by the scrub practitioner without being retained for counting. Of course, the fact that some syringes are apparently manufactured with a cap and others without complicates the situation but is not actually a bar to counting the number of caps present at the outset of the operation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to implement recommended strategies to reduce recurrence of plastic obstruction incidents
Wider context from the report “(1) If a simple precaution was taken in ensuring that the tip of a bulb syringe or similar was a different colour to the rest of the equipment then it is difficult to see how a surgeon could use a syringe with the tip still in place by error. As the attached photograph shows there is no significant difference between the syringe with the tip on or off.
(2) There is a further concern in respect of other information which is contained with the Trust’s SUI report as follows:
It is perhaps of some relevance that in 2001-2 a number of instances of items of anaesthetic airway equipment being blocked with extraneous pieces of plastic and causing harm to patients were the subject of a national police investigation (Operation Cordian). The police findings were examined by an Expert Group, which published a series of recommendations in 2004. Their conclusion was that there was no criminal intent but that the incidents had happened as a matter of chance. Strategies to reduce the chances of these events recurring were recommended. Recommendation 1 states “The MHRA should recommend to manufacturers and the relevant Standards Committees that ….. detachable caps (eg. On intravenous cannulae and giving sets) be manufactured in brightly coloured material, preferably red, to aid visibility”.
No action appears to have been taken in consequence of this.
(3) The SUI report goes on to indicate that none of the team undertaking the operation were aware that the bulb syringe came supplied with a cap. The previous brand used by the Trust was not supplied with a syringe cap. The current bulb syringes in use obviously do have a cap but this is normally removed by the scrub practitioner before the syringe is supplied to the operating surgeon. Thus there has been little opportunity for surgeons to appreciate that syringes now have caps. This underlines the importance of ensuring that such devices are manufactured with a brightly coloured cap, if one is to be used at all.
(4) There appears to be no standard procedure for checking for syringe caps (where used) at the end of the operation, such as there is with swabs. The evidence available to me suggests that items such as syringe caps are just discarded by the scrub practitioner without being retained for counting. Of course, the fact that some syringes are apparently manufactured with a cap and others without complicates the situation but is not actually a bar to counting the number of caps present at the outset of the operation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 operating staff are aware that bulb syringes are supplied with caps
Wider context from the report “(1) If a simple precaution was taken in ensuring that the tip of a bulb syringe or similar was a different colour to the rest of the equipment then it is difficult to see how a surgeon could use a syringe with the tip still in place by error. As the attached photograph shows there is no significant difference between the syringe with the tip on or off.
(2) There is a further concern in respect of other information which is contained with the Trust’s SUI report as follows:
It is perhaps of some relevance that in 2001-2 a number of instances of items of anaesthetic airway equipment being blocked with extraneous pieces of plastic and causing harm to patients were the subject of a national police investigation (Operation Cordian). The police findings were examined by an Expert Group, which published a series of recommendations in 2004. Their conclusion was that there was no criminal intent but that the incidents had happened as a matter of chance. Strategies to reduce the chances of these events recurring were recommended. Recommendation 1 states “The MHRA should recommend to manufacturers and the relevant Standards Committees that ….. detachable caps (eg. On intravenous cannulae and giving sets) be manufactured in brightly coloured material, preferably red, to aid visibility”.
No action appears to have been taken in consequence of this.
(3) The SUI report goes on to indicate that none of the team undertaking the operation were aware that the bulb syringe came supplied with a cap . The previous brand used by the Trust was not supplied with a syringe cap. The current bulb syringes in use obviously do have a cap but this is normally removed by the scrub practitioner before the syringe is supplied to the operating surgeon. Thus there has been little opportunity for surgeons to appreciate that syringes now have caps . This underlines the importance of ensuring that such devices are manufactured with a brightly coloured cap, if one is to be used at all.
(4) There appears to be no standard procedure for checking for syringe caps (where used) at the end of the operation, such as there is with swabs. The evidence available to me suggests that items such as syringe caps are just discarded by the scrub practitioner without being retained for counting. Of course, the fact that some syringes are apparently manufactured with a cap and others without complicates the situation but is not actually a bar to counting the number of caps present at the outset of the operation.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing manufacturer safety measures, NHS surgical never-event work and revised guidance are considered sufficient to address the concerns and prevent future deaths.
Verbatim wording from the response “I am pleased to note that the MHRA has made significant progress in discussions with Rocielle - the manufacturers of the syringes and have written to let you know that the manufacturers;” Source location 2013-0368-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for medicines and devices, including syringes, rests with the MHRA, which is gathering information on the case.
Verbatim wording from the response “I am aware that you have contacted the Medicines and Healthcare Regulatory Authority (MHRA), which is the body with responsibility for medicines and devices (including syringes), and that officials there are gathering information on this case, with a view to providing evidence to the inquest when it reconvenes.” Source location 2013-0368-Response-by-Department-of-Health
Open published response
13 Dec 2013 STEPHANIE DANIELS · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 9 Failure to complete and record patient observations View source Lack of nurse review of recent records during admission or transfer handover View source Delays in admission to an appropriate mental health bed View source Failure to properly clerk in mental health patients View source Failure to implement handover policies in practice View source Lack of clinical supervision and guidance for junior medical staff View source Failure to conduct prompt, thorough and independent investigations of serious patient deaths View source Failure of junior medical staff to review clinical records and history before prescribing medication View source Lack of a reliable method for notifying the responsible Consultant of patient admission View source See 6 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
STEPHANIE DANIELS · 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
Stephanie Daniels, who had a history of serious mental health problems and repeated self-harm, was admitted to the Safire unit on 22 March 2012 after a delay in securing an inpatient bed. She died there on 24 March 2012 after being found unconscious with a ligature around her neck. The principal concerns included inadequate observation and handover, failure to clerk her in, medication-recording and supervision problems, failures in the emergency response, and deficiencies in the subsequent internal investigation.
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 complete and record patient observations
Wider context from the report “8. Performing and recording observations on other patients
I was concerned about the discovery of incomplete written observations for another patient where there are significant gaps in the records and may illustrate a systemic problem because the patient was transferred to a different ward. This was only discovered during the course of the inquest and was brought to the attention of MHSC so that they could carry out their own investigations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 nurse review of recent records during admission or transfer handover
Wider context from the report “2. Handover
All the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care. MHSC have introduced a new policy but I have a concern that simple issues may be overlooked. For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records . MHSC have produced new or updated policies/protocols but experience has shown that what may be delivered on paper is not being done in practice. Consequently, I am concerned that without appropriate audit and clinical/nursing leadership this may prove to be ineffective.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 admission to an appropriate mental health bed
Wider context from the report “3. Bed Availability
MHSC say that following the death of the deceased, a new policy has been introduced so that there is no waiting time at all for the allocation of a bed in the case of a patient who is deemed clinically to require one. A bed will be found somewhere which will be appropriate to their needs. As I understood the evidence from the CCG in the case this should have occurred in any event. However, other NHS Trusts nationwide who do not have such a policy, may have patients whose delayed admission means that they are not having the appropriate nursing and clinical input, as well as medication review . In turn this means their condition may continue to deteriorate and when effective care does start, the patient may well be more ill than they should be. I am concerned that the importance of this is recognised not only by MHSC but nationally for all other NHS mental health 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 properly clerk in mental health patients
Wider context from the report “4. Clerking In
The failure to properly clerk in the patient is a matter of serious concern , especially as many such patients will have physical health problems. MHSC had clear policies requiring the clerking in of a patient, but these were simply not adhered to . It is very common for patients with mental health problems to have associated physical conditions which require appropriate monitoring and treatment. It seems that despite the existence of appropriate policies, in practice these were not being complied with . Whether or not any new or different policy or auditing of compliance is the way to achieve uniformity is a matter for MHSC. I repeat what I have said earlier. MHSC have produced new or updated policies/protocols but experience has shown that what may be delivered on paper is not being done in practice. Consequently, I am concerned that without appropriate audit and clinical/nursing leadership this may prove to be ineffective.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to implement handover policies in practice
Wider context from the report “2. Handover
All the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care. MHSC have introduced a new policy but I have a concern that simple issues may be overlooked. For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records. MHSC have produced new or updated policies/protocols but experience has shown that what may be delivered on paper is not being done in practice . Consequently, I am concerned that without appropriate audit and clinical/nursing leadership this may prove to be ineffective .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical supervision and guidance for junior medical staff
Wider context from the report “5. Supervision of Junior Medical Staff
I am concerned about the lack of appropriate clinical supervision and guidance for junior medical staff . Two junior doctors were asked to attend the ward and made no appropriate clinical records of the reason for their attendance, reviewing the records, seeing the patient and explaining any clinical decision to prescribe medication. It is appreciated that they are busy with a number of duties but it is a matter of concern that they did not undertake basic clinical recording duties for a patient who clearly should have been seen. They did not notice that the patient had not been clerked in. Medication was being prescribed without adequate consideration of the relevant clinical history. They did not notice the named Consultant in charge of the patient was unaware of the admission. Appropriate clinical supervision would be expected to ensure an appropriate standard of performance. I understand that supervision may be delegated by the North West Deanery to the relevant NHS Trust but there has to be some basic accepted levels of interaction, communication and supervision between the junior Doctors and their Consultants to ensure an appropriate standard and continuity of care. This may be a joint responsibility between the Deanery and the NHS trust involved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct prompt, thorough and independent investigations of serious patient deaths
Wider context from the report “1. Internal NHS SUI Investigation v Independent Investigation
I am concerned that a death such as this of either a detained or voluntary patient (where Article 2 is arguably engaged) requires a prompt, thorough and robust investigation to be completed as soon as possible. Deficiencies in systems, protocols, policies, record keeping and individual actions need to be identified quickly and remedial action taken. This cannot wait for an inquest which may not take place for many months. This was not the first case of a poor or incomplete SUI investigation. The court was aware of and invited submissions about the recent case of R (Antoniou) v Central and North West London NHS Foundation Trust and others [2013] EWHC 3055 (Admin).
In this case there were significant errors and omissions in the SUI investigation . Important witnesses were not interviewed. The delay in finding the deceased a bed was not a central issue and no specific findings were made about it. The medication recording errors had not been noted and had the deceased been injected with PRN Haloperidol for severe agitation, then she should have been subject to physical observations for a continuous period of time immediately afterwards, as well as other steps in compliance with the Trust’s Rapid Tranquilisation Policy. It is accepted that SUI investigations are important and hope to learn lessons quickly to be implemented. Whilst the current law indicated that it is not a requirement for there to be an independent investigation at that stage, it is a matter of concern that very significant failures in the investigative process have occurred. The Trust investigation did not reveal at all the allegation of the commencement of discreet continuous observations on the morning of 24th March.
This is not the first time that the Trust SUI investigations have been found to be flawed and I have experience of other Trusts’ investigations also being significantly flawed. In conclusion in this sort of case I am concerned that without appropriately speedy and thorough independent investigation commissioned by the NHS Trust involved, flawed SUI investigation reports may continue to be produced . This is a policy decision for the NHS but I strongly urge consideration of this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 junior medical staff to review clinical records and history before prescribing medication
Wider context from the report “6. Prescribing of Medication by Junior Medical Staff
I am concerned by the circumstances in this case where medication came to be prescribed. There is an overlap of my concerns about supervision and my observations at paragraph 5 above should be regarded as repeated here. Both junior doctors had no recollection of attending the ward, speaking to the staff or seeing the patient. They simply prescribed the medication. They had no recollection of reviewing the deceased’s records and understood that was essential when considering prescribing any medication, and in particular PRN rapid tranquillisation. In this case, the patient was already taking a number of drugs which had sedative effects. Two further medications were introduced that have similar properties and that also could potentially affect heart function.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 reliable method for notifying the responsible Consultant of patient admission
Wider context from the report “7. Mechanism by which the Consultant in charge of the patient would learn of the patient’s admission
It is of concern that there was apparently no simple method of ensuring that the Consultant in whose name the patient was admitted became aware of the admission and could therefore ensure appropriate clinical leadership and review was undertaken. It would seem that there could be a number of simple solutions for this problem.
” 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 Trust-level policy and procedural concerns are assigned to the NTDA and Manchester Health and Social Care Trust.
Verbatim wording from the response “As many of the concerns you raise are issues to be dealt with at Trust level, I have ensured that your concerns have been sent to the National Trust Development Authority (NTDA) which provides support, oversight and governance for all NHS Trusts. The NTDA is in contact with MHSCT Trust and has received an action plan which seeks to address the points you have raised.” Source location 2013-0353-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Acute beds should already be available without waiting for patients clinically deemed to need them.
Verbatim wording from the response “Your report stated that there should be no waiting time for the allocation of a bed in the case of a patient who is clinically deemed to need one. As the evidence given by the Clinical Commissioning Group in this case stated, this should already be the case. We are clear that acute beds must always be available for people who need them.” Source location 2013-0353-Response-by-Department-of-Health
Open published response
6 Dec 2013 Millie Elizabeth Josephine Thompson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Insufficient paediatric first aid training among nursery staff View source Failure of ambulance call-takers to correctly assess breathing and triage calls View source Lapsed first aid certification among staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Millie Elizabeth Josephine Thompson · 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
Millie Elizabeth Josephine Thompson, aged 9 months, choked while being fed Shepherd’s Pie at a nursery on 23 October 2012. Food lodged in her left main bronchus, leading to a tension pneumothorax and cardiac arrest. Concerns included insufficient paediatric first-aid training and lapsed certification among nursery staff, an incorrect ambulance call allocation, and unsuitable paediatric equipment on the first ambulance.
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 paediatric first aid training among nursery staff
Wider context from the report “During the course of the evidence it became apparent that there were only a few members of staff at the Nursery who had undergone Paediatric First Aid training , and that there is a need for specialist training when confronted with certain medical conditions affecting very young children . Other members of staff had general First Aid training but this appears to have been less useful in the circumstances .
It also transpired that the First Aid certification of some of the staff had lapsed by the passage of time, so that although they had undergone the training it now needed updating.
The EMD (call-taker) for the Ambulance Trust is a non-medically trained person who simply takes the details and reads from the appropriate “card” as to what questions should be asked and what advice should be given as well as determining how the case is to be triaged and allocated. It appears that because of a misinterpretation by that person as to the question of “ineffective/effective breathing”, the case was wrongly allocated.
I took the view that ALL nursery staff should be subject to mandatory paediatric First Aid training; that there should be better selection and training of Call-Takers for the ambulance service; that ALL emergency ambulances (including rapid response vehicles) should be equipped with suitable paediatric life-saving kit.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 ambulance call-takers to correctly assess breathing and triage calls
Wider context from the report “During the course of the evidence it became apparent that there were only a few members of staff at the Nursery who had undergone Paediatric First Aid training, and that there is a need for specialist training when confronted with certain medical conditions affecting very young children. Other members of staff had general First Aid training but this appears to have been less useful in the circumstances.
It also transpired that the First Aid certification of some of the staff had lapsed by the passage of time, so that although they had undergone the training it now needed updating.
The EMD (call-taker) for the Ambulance Trust is a non-medically trained person who simply takes the details and reads from the appropriate “card” as to what questions should be asked and what advice should be given as well as determining how the case is to be triaged and allocated. It appears that because of a misinterpretation by that person as to the question of “ineffective/effective breathing”, the case was wrongly allocated .
I took the view that ALL nursery staff should be subject to mandatory paediatric First Aid training; that there should be better selection and training of Call-Takers for the ambulance service; that ALL emergency ambulances (including rapid response vehicles) should be equipped with suitable paediatric life-saving kit.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lapsed first aid certification among staff
Wider context from the report “During the course of the evidence it became apparent that there were only a few members of staff at the Nursery who had undergone Paediatric First Aid training, and that there is a need for specialist training when confronted with certain medical conditions affecting very young children. Other members of staff had general First Aid training but this appears to have been less useful in the circumstances.
It also transpired that the First Aid certification of some of the staff had lapsed by the passage of time , so that although they had undergone the training it now needed updating .
The EMD (call-taker) for the Ambulance Trust is a non-medically trained person who simply takes the details and reads from the appropriate “card” as to what questions should be asked and what advice should be given as well as determining how the case is to be triaged and allocated. It appears that because of a misinterpretation by that person as to the question of “ineffective/effective breathing”, the case was wrongly allocated.
I took the view that ALL nursery staff should be subject to mandatory paediatric First Aid training; that there should be better selection and training of Call-Takers for the ambulance service; that ALL emergency ambulances (including rapid response vehicles) should be equipped with suitable paediatric life-saving kit.
” 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 Responsibility for selecting and training ambulance call-taking staff rests with the North West Ambulance Service Trust.
Verbatim wording from the response “I note that you have sent a copy of this Regulation 28 report to the Department for Education (DfE) and the North West Ambulance Service Trust (NWAS). The training of nursery staff is the responsibility of DfE whilst the selection and training of call taking staff at the NWAS is a matter for the NWAS Trust. I believe that these two issues should properly be addressed by the DfE and the NWAS.” Source location 2013-0356-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for mandatory paediatric first-aid training of nursery staff rests with the Department for Education.
Verbatim wording from the response “I note that you have sent a copy of this Regulation 28 report to the Department for Education (DfE) and the North West Ambulance Service Trust (NWAS). The training of nursery staff is the responsibility of DfE whilst the selection and training of call taking staff at the NWAS is a matter for the NWAS Trust. I believe that these two issues should properly be addressed by the DfE and the NWAS.” Source location 2013-0356-Response-by-Department-of-Health
Open published response
3 Dec 2013 Horace Cottom · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Failure to provide prison healthcare professionals with timely and complete discharge information View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Horace Cottom · 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
Horace Cottom, a serving prisoner at HMP Manchester, died there on 21 June 2012 from pneumonia and heart disease with pseudomembranous colitis, with the inquest concluding that the death was from natural causes. The principal concern was that discharge information from NHS hospitals could take about 10 days to reach the prison and was sometimes incomplete, affecting the timely management of prisoners’ healthcare after hospital discharge.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prison healthcare professionals with timely and complete discharge information
Wider context from the report “However, the inquest did establish that following his last discharge, it took about 10 days for any discharge information/report to be received at the prison from the NHS hospital . Further enquiries revealed that this was quite common and locally in Manchester the prison service tried to get the discharging doctor to write out in manuscript form discharge information. This is not always successful and results in delay, as well as incomplete discharge information.
Recently, HMPS changed from using the NHS EMIS GP recording system and introduced what is known as 'System One'. This means that it is certainly easier for a prisoner who moves within the HMPS estate to have their GP records accessed immediately within the prison system.
Locally in Manchester, they also try to use an email system to collect discharge information, but this is not without problems itself. From what I was told at the inquest, it seems that some NHS information can be transmitted directly onto the System One, but for some reason discharge information is not sent.
HMPS caters for an increasing number of older prisoners with chronic health problems who have to attend outside NHS hospitals for investigations and treatment. It is vital that the healthcare professionals in prison have timely and full discharge information so that they can manage the care of the patient prisoner once they are returned to custody. One would hope that there is a simple and user-friendly way in which discharge information could be relayed to all prison healthcare establishments via the NHS. Whilst this has been highlighted as a local issue, I anticipate that it actually will be replicated nationwide. Accordingly, I am writing this letter under paragraph 37 & 38 of the enclosed Chief Coroner's Guidance No. 5 to bring this to your attention.
I appreciate that it will involve a number of others who can assist in resolving the position and therefore I am also going to send a copy of this letter to the Chief Executive of the NHS, the Minister for Prisons, the Director General of HMPS, the Governor of HMP Manchester, as well as the Medical Directors of the major NHS Trusts in Greater Manchester. I sincerely hope a solution can be found.
” Open source report
21 Nov 2013 Peter Galea · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 2 Limited mechanisms for breaking referral cycles between agencies View source Limitations on GPs making direct referrals for admission to a place of safety View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Peter Galea · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Galea, a 51-year-old man, attended hospital and other agencies repeatedly over a 72-hour period and was assessed as low risk on three occasions. On 11 June, after leaving his GP surgery and threatening to jump from a bridge, his body was found under the Queen Alexandra Bridge and he was pronounced dead. Concerns included limited mechanisms for breaking referral cycles, restrictions on direct GP referral for admission to a place of safety, and whether different action might have prevented the outcome.
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 Limited mechanisms for breaking referral cycles between agencies
Wider context from the report “Mr Galea was not known to mental health services and experienced multiple presentations to a number of professionals and agencies within a 72 hour period and had 3 mental health assessments, all of which placed him at a low risk.
Whilst it is a tragedy that the professionals and agencies did not have more of an opportunity to work with Mr Galea before he took his own life, I was concerned, that: -
1) there appeared to be limited mechanisms available to break the cycle of referrals between agencies without more positive action being taken whereby Mr Galea could be in a safe place whilst a more detailed assessment of his needs could be carried out possibly involving a psychiatrist . The family described the referral between agencies as “ping pong”.
2) there were limitations upon the GP making a direct referral to have Mr Galea admitted to Cherry Knowle Hospital, because to do so Mr Galea would have had to go back to the Mental Health Team, with whom he had had three contacts within a 72 hour period. From the evidence it was clear that the GP had a positive relationship with his patient (for 4 years) and although prospectively acquiescing to the patient’s wishes, in exceptional circumstances, it may be that a GP should be able to achieve an admission to a place of safety, even if only for a limited period of time. I readily acknowledge some of the disadvantages which may come into play by way of admission but in raising it there may also be advantages which would promote a patient’s welfare.
3) I was grateful for the assistance of ████████ Consultant Psychiatrist, but he was not able to offer to me any view about what may have been done differently for Mr Galea to avoid this very tragic outcome. In raising the matter with you, it may be that some solution to enhance patient’s welfare and wellbeing can be found to prevent future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Limitations on GPs making direct referrals for admission to a place of safety
Wider context from the report “Mr Galea was not known to mental health services and experienced multiple presentations to a number of professionals and agencies within a 72 hour period and had 3 mental health assessments, all of which placed him at a low risk.
Whilst it is a tragedy that the professionals and agencies did not have more of an opportunity to work with Mr Galea before he took his own life, I was concerned, that: -
1) there appeared to be limited mechanisms available to break the cycle of referrals between agencies without more positive action being taken whereby Mr Galea could be in a safe place whilst a more detailed assessment of his needs could be carried out possibly involving a psychiatrist. The family described the referral between agencies as “ping pong”.
2) there were limitations upon the GP making a direct referral to have Mr Galea admitted to Cherry Knowle Hospital, because to do so Mr Galea would have had to go back to the Mental Health Team , with whom he had had three contacts within a 72 hour period. From the evidence it was clear that the GP had a positive relationship with his patient (for 4 years) and although prospectively acquiescing to the patient’s wishes, in exceptional circumstances, it may be that a GP should be able to achieve an admission to a place of safety, even if only for a limited period of time. I readily acknowledge some of the disadvantages which may come into play by way of admission but in raising it there may also be advantages which would promote a patient’s welfare.
3) I was grateful for the assistance of ████████ Consultant Psychiatrist, but he was not able to offer to me any view about what may have been done differently for Mr Galea to avoid this very tragic outcome. In raising the matter with you, it may be that some solution to enhance patient’s welfare and wellbeing can be found to prevent future deaths.
” Open source report
Concerns raised 8 Lack of national standardised guidance on the management of ventilation in neonates View source Failure to routinely check medical records for new neonatal admissions View source Failure to routinely use disposable exhaled carbon dioxide detectors on the NNU View source Failure to ensure effective oversight and monitoring of the ventilatory pressure dial following intubation View source Lack of national standardised guidance on the management and administration of paralysing agents to neonates needing intubation View source Failure to make treatment decisions collaboratively and using all available information View source Lack of individualised neonatal nursing care plans View source Failure to provide 1:1 neonatal nurse/cotside handover at shift change View source See 5 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
Jack William PARTINGTON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jack Partington was born by planned caesarean section on 25 November 2011 and developed breathing difficulties requiring neonatal ventilation. After developing a pneumothorax, he was treated with intubation and ventilation but deteriorated and died on 26 November 2011. Concerns included gaps in neonatal handover and care planning, treatment decisions made without multidisciplinary consultation, lack of routine use of exhaled carbon dioxide detectors, absence of national guidance on paralysing agents and neonatal ventilation, and inadequate monitoring of ventilatory pressure after intubation.
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 standardised guidance on the management of ventilation in neonates
Wider context from the report “4) There are no national standardised policies, protocols or guidance on the management and administration of paralysing agents to neonates in need of intubation and/or the management of ventilation in neonates .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely check medical records for new neonatal admissions
Wider context from the report “1) That there was no 1:1 neonatal nurse/cotside ‘handover’ at shift change, no individualised neonatal nursing care plan in use and no routine checks of medical records for new neonatal admissions .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely use disposable exhaled carbon dioxide detectors on the NNU
Wider context from the report “3) That disposable exhaled carbon dioxide detectors (ET CO2) were not routinely used on the NNU (as an adjunct) and that they are not currently/routinely used in many NNUs throughout the country.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 effective oversight and monitoring of the ventilatory pressure dial following intubation
Wider context from the report “5) No single individual within the neonatal (resuscitation) team was allocated to oversee and monitor the ventilatory pressure dial following intubation. The dial in question was situated on the side of the incubator/cot, out of the direct line of sight of the clinician controlling the airway/ventilatory process.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 standardised guidance on the management and administration of paralysing agents to neonates needing intubation
Wider context from the report “4) There are no national standardised policies, protocols or guidance on the management and administration of paralysing agents to neonates in need of intubation and/or the management of ventilation in neonates.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 treatment decisions collaboratively and using all available information
Wider context from the report “2) Nursing staff, rather than the multi-disciplinary team plus parents, took treatment/change of treatment decisions in isolation and without consulting all available information (such as medical records etc.)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 individualised neonatal nursing care plans
Wider context from the report “1) That there was no 1:1 neonatal nurse/cotside ‘handover’ at shift change, no individualised neonatal nursing care plan in use and no routine checks of medical records for new neonatal admissions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 1:1 neonatal nurse/cotside handover at shift change
Wider context from the report “1) That there was no 1:1 neonatal nurse/cotside ‘handover’ at shift change , no individualised neonatal nursing care plan in use and no routine checks of medical records for new neonatal admissions.
” 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 Staffing, training, governance and clinical issues are local matters that should be addressed by the NHS Trust.
Verbatim wording from the response “I note that you have sent a Regulation 28 report to the local NHS Trust for its response. I believe that the issues concerning staffing, staff training, governance and clinical issues are local issues that should properly be addressed by the Trust.” Source location 2013-0308-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 neonatal service care guidance should cover carbon dioxide detectors and paralysing agents, so duplicate national guidance is unnecessary.
Verbatim wording from the response “Guidance on the use of carbon dioxide detectors and the management and administration of paralysing agents to neonates in need of intubation should already be covered in the care guidance of every neonatal service. We do not therefore believe issuing duplicate guidance would be valuable. The Resuscitation Council (UK) has issued updated guidance on new-born life support, which recommends detection of exhaled carbon dioxide in addition to clinical assessment as the most reliable method to confirm placement of a tracheal tube in neonates with a spontaneous circulation. We have been advised by NHS England that carbon dioxide monitors are being used increasingly in neonatal units. However, their use in individual cases is a matter for the clinical judgement of the health professionals involved.” Source location 2013-0308-Response-by-Department-of-Health
Open published response
14 Nov 2013 Anthony Brian Flynn · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Failure to acknowledge and investigate clinicians’ concerns about prisoner treatment View source Lack of clinician awareness of powers to request changes to prisoners’ restraints 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
Anthony Brian Flynn · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony Brian Flynn, who had diagnosed testicular cancer, was remanded into custody at Forest Bank Prison on 24 July 2012 and died there on 28 September 2012. The report raised concerns that he was handcuffed and chained during hospital appointments and examination, that a consultant’s concerns about the lack of compassion and difficulty conducting a sensitive examination were not acknowledged or investigated, and that training and procedures concerning restraints and clinicians’ powers needed consideration.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to acknowledge and investigate clinicians’ concerns about prisoner treatment
Wider context from the report “(3) On the 10th September 2012, ████████ a Consultant Clinical Oncologist at the Royal Preston Hospital who was treating Mr Flynn, wrote to HMP Forest Bank expressing concerns. She said “I was extremely concerned that there was an absolute lack of compassion demonstrated to what was a very sick man who was extremely distressed in the clinic. Unfortunately I felt that there was no really empathy in terms of the huge amount he had already received treatment for the significant side effects he has had and certainly conducting my examination of the abdomen and pelvis including the genitalia in a sensitive manner was extremely difficult.” Evidence given at the Inquest confirmed that Mr Flynn had been chained and handcuffed during the examination to which the Doctor refers.
(4) ████████ letter was received at HMP Forest Bank, but it was never acknowledged. No reply was sent, nor were the matters of concern described in the letter, especially that the Doctor had found it ‘extremely difficult’ to conduct the examination of Mr Flynn, ever investigated.
(5) Further evidence given at the Inquest revealed that:
a) When a prisoner is being escorted to hospital or other appointments escorting officers can, if they consider it appropriate, telephone the prison and seek permission to remove or lengthen the prisoner’s restraints.
b) Clinicians have the power to request that the action described in a) be taken, but most clinicians are unaware that they can do this.
(6) The evidence concluded that there was a need to consider the following:
a) The training of prison officers in relation to escorting prisoners, particularly during hospital visits.
b) Procedures for making clinicians, particularly hospital clinicians, aware of their powers in relation to prisoners attending for treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician awareness of powers to request changes to prisoners’ restraints
Wider context from the report “(3) On the 10th September 2012, ████████ a Consultant Clinical Oncologist at the Royal Preston Hospital who was treating Mr Flynn, wrote to HMP Forest Bank expressing concerns. She said “I was extremely concerned that there was an absolute lack of compassion demonstrated to what was a very sick man who was extremely distressed in the clinic. Unfortunately I felt that there was no really empathy in terms of the huge amount he had already received treatment for the significant side effects he has had and certainly conducting my examination of the abdomen and pelvis including the genitalia in a sensitive manner was extremely difficult.” Evidence given at the Inquest confirmed that Mr Flynn had been chained and handcuffed during the examination to which the Doctor refers.
(4) ████████ letter was received at HMP Forest Bank, but it was never acknowledged. No reply was sent, nor were the matters of concern described in the letter, especially that the Doctor had found it ‘extremely difficult’ to conduct the examination of Mr Flynn, ever investigated.
(5) Further evidence given at the Inquest revealed that:
a) When a prisoner is being escorted to hospital or other appointments escorting officers can, if they consider it appropriate, telephone the prison and seek permission to remove or lengthen the prisoner’s restraints.
b) Clinicians have the power to request that the action described in a) be taken, but most clinicians are unaware that they can do this.
(6) The evidence concluded that there was a need to consider the following:
a) The training of prison officers in relation to escorting prisoners, particularly during hospital visits.
b) Procedures for making clinicians, particularly hospital clinicians, aware of their powers in relation to prisoners attending for treatment.
” Open source report
Concerns raised 1 Repetition of similar unsafe circumstances 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
Kathleen Rosemary Dixon · 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
Kathleen Rosemary Dixon was receiving treatment for mental illness that was escalating, but its severity was not recognised by those treating her, and she drowned in a river. The concern raised was that similar circumstances had occurred in previous inquests and that the Trust should be assessed independently.
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 Repetition of similar unsafe circumstances
Wider context from the report “(1) This is a repetition of similar circumstances in a number of previous Inquests and I think the Trust needs to be assessed independently.
” Open source report
1 Nov 2013 Rachael Claire Slack and 2 others · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1 Failure to exchange relevant information between Police and Mental Health Services 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
Rachael Claire Slack and 2 others · 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 2 June 2010, Andrew David Cairns entered Rachael Claire Slack’s home, stabbed their son Auden George Slack and Rachael Slack to death, and then stabbed himself to death. The principal concerns were failures in information-sharing between Police and Mental Health Services, and failures to communicate the assessed risk and safety measures to Rachael regarding the threat posed by Andrew.
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 exchange relevant information between Police and Mental Health Services
Wider context from the report “1. At the time of arrest of Mr Cairns, the Police were aware of his assessment under Section 136 of the Mental Health Act the previous day. The Custody Nurse had contacted the Crisis Team to obtain information regarding the 136 assessment which was duly given by the Mental Health Team. However, there was no reciprocal exchange of information and the Mental Health Team were not informed that Mr Cairns had been arrested with regards to Threats to Kill his partner.
2. At the conclusion of the Inquest and after all the evidence was heard, it came to light that there was in existence a policy for mutual sharing of information between the Police and Mental Health Services if each respective organisation requested information from the other.
3. This document was not disclosed prior to the Inquest or during the Inquest itself and it would have been critical to ask witnesses from the Police and Mental Health Services about their knowledge of this document.
” Open source report
Concerns raised 2 Failure to factor critical clinical information into operator advice View source Failure of the ambulance service computer programme to take account of critical clinical information 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
Winston Llewellyn Johns · 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
Winston Llewellyn Johns was found unrousable with a blood sugar level of 1.4 during a 999 call. He was advised to undergo CPR, sustained a sternum fracture and multiple rib fractures, and later died in hospital from pneumonia caused by those fractures. The concerns were that the low blood sugar information was not factored into the advice and that the ambulance service’s computer programme contributed to CPR being incorrectly advised.
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 factor critical clinical information into operator advice
Wider context from the report “(1) Mr Johns son clearly confirmed the low blood sugar at the beginning of the call. This critical important information was not factored into the advice provided to him by the operator.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 ambulance service computer programme to take account of critical clinical information
Wider context from the report “(2) The computer programme used by the ambulance service does not take into account critical clinical information as a result the operator incorrectly advised CPR despite the risks that entails.
” Open source report
24 Oct 2013 Peter Clive HIGSON · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Potential contraindication of platelet transfusion following stem cell transplant View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Peter Clive HIGSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Clive Higson had treated Hodgkin’s lymphoma and underwent an autologous stem cell transplant before being admitted to hospital with severe illness. After platelet transfusions, his breathing and overall condition deteriorated; the principal concern was whether the transfusions, possibly interacting with the stem cell transplant, contributed to the chain of events leading 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 Potential contraindication of platelet transfusion following stem cell transplant
Wider context from the report “The platelet transfusion (12 & 13th March 2013) following the stem cell transplant (28th January 2013, seemed to have a major detrimental effect on the deceased and features, if only chronologically, in the ultimate chain of causation leading to his death.
A question arises as to whether there was any aspect of e.g., the stem cell transplant interacting with the platelet transfusion suggesting that on occasions such transfusion might be contra-indicated .
” 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 Prophylactic platelet transfusion was appropriate, and respiratory deterioration was likely caused by factors other than the transfusion.
Verbatim wording from the response “NHSBT provided a report on the circumstances leading up to the death of Mr Higson, together with information on the measures in place to minimise the risk of an adverse outcome to a platelet transfusion. On the basis of this, it appears that prophylactic platelet transfusion was an appropriate treatment for Mr Higson, and that the respiratory deterioration leading up to his death is likely to have resulted from causes other than the transfusion.” Source location 2013-0277-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Platelet transfusion is not considered contraindicated in similar patients, so no action is considered necessary to prevent future deaths.
Verbatim wording from the response “Given these points, it does not appear that platelet transfusion would be contra-indicated for patients in Mr Higson’s situation, or that action is required to prevent future deaths in similar circumstances.” Source location 2013-0277-Response-by-Department-of-Health
Open published response
Concerns raised 4 Failure to identify difficulties experienced by patients on Section 17 leave View source Failure to stop trains and set signals to danger when an unwell person is trespassing on the line View source Lack of clear guidance on whether lung decompression needles should be used with a valve View source Failure to gather and pass accurate trespasser and track-section location information View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Daniel Maurice McMahon · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel Maurice McMahon suffered severe head injuries after being hit by a train at Willesden Junction Station on 11 January 2012, following reports that he had fallen from a bridge and moved onto the railway track. The report raised concerns about the accuracy and completeness of information recorded by police about the location of a person trespassing on the railway, procedures for stopping trains when an unwell person is on the line, support during mental-health leave, and the use of lung-decompression needles without a valve.
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 identify difficulties experienced by patients on Section 17 leave
Wider context from the report “(2) Department of Health:-
Consideration to be given to using a feedback form, where a patient is on S17 of the MHA 1983 leave, to be completed by those caring for the patient in the community and the professional staff at the hospital to ensure that any difficulties that a patient has while on leave are picked up
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 stop trains and set signals to danger when an unwell person is trespassing on the line
Wider context from the report “(3) RSSB:-
The Rule book be amended to require that trains stop, (signals are set to danger), when a person who is identified as being unwell or there is reason to believe might be unwell is trespassing on the line . (The current position would be to set the signals to caution ).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance on whether lung decompression needles should be used with a valve
Wider context from the report “(4) London Ambulance Service:-
The LAS consider the guidance on the use of lung decompression needles and whether these should be used with a valve .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 gather and pass accurate trespasser and track-section location information
Wider context from the report “(1) Metropolitan Police :-
That steps should be taken to ensure that when report is passed to the police concerning a person who is seen to be trespassing on the railway line that correct information is gathered to locate that person and the section of the track that person is on so that this information can be passed to those responsible for contacting the network covering that section of the track . This is in addition to the attendance location and the incident location normally recorded when a 999 call is made.
” 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 Review the Code of Practice on section 17 leave of absence and care planning, informed by this case.
Verbatim wording from the response “We are currently reviewing the advice in the “Code of Practice Mental Health Act 1983”. This includes reviewing the chapter on leave of absence under section 17 of the Mental Health Act 1983 and the references to care planning. The experience of this case will be used to assist that review.” Source location 2013-0271-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The London Ambulance Service is responsible for responding to the concern about its crew’s use of a decompression needle without a valve.
Verbatim wording from the response “I understand the London Ambulance Service will reply to you directly on your concern about their crew’s use of a decompression needle without a valve.” Source location 2013-0271-Response
Open published response
Concerns raised 2 Danger of treating caffeine-containing energy mints as ordinary sweets View source Lack of information on caffeine levels and the dangers of consuming large amounts of caffeine 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
JOHN JAMES JACKSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
JOHN JAMES JACKSON was found dead at his home, and life was pronounced extinct at 12 noon on 2 May 2013. Evidence indicated that he was a compulsive user of Hero Energy Mints and had more than twice the blood caffeine level reported as capable of producing a fatality. The concerns included limited information about the product’s caffeine content and the dangers of consuming large quantities, and its position between medication and sweets.
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 Danger of treating caffeine-containing energy mints as ordinary sweets
Wider context from the report “I heard and accepted evidence that the deceased was a compulsive user of a product called “Hero Energy Mints”. This produce is advertised as having “More than all the normal advantages of energy drinks in an easy to use format”. The advertising says that one mint equals one whole energy drink. It went onto say that the product contains caffeine. However, the information available on the internet at the time of the inquest contained no information at all as to the dangers of consuming large quantities of the mints. At the inquest, the evidence from the pathologist showed that Mr. Jackson had in his blood at the time of death, more than twice the level of caffeine that can produce a fatality and around 50 times the level that would be found normally in someone drinking tea and coffee.
a) There was at the time little information available as to the level of caffeine in this product and the dangers of consuming large amounts of caffeine,
b) The product seems to me to sit uncomfortably in a gap between medication and sweets , when any person treating the product simply as sweets maybe in danger . I acknowledge of course, that part of the answer is public awareness and I trust that the publicity that was given to this case may assist in that regard.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 information on caffeine levels and the dangers of consuming large amounts of caffeine
Wider context from the report “I heard and accepted evidence that the deceased was a compulsive user of a product called “Hero Energy Mints”. This produce is advertised as having “More than all the normal advantages of energy drinks in an easy to use format”. The advertising says that one mint equals one whole energy drink. It went onto say that the product contains caffeine. However, the information available on the internet at the time of the inquest contained no information at all as to the dangers of consuming large quantities of the mints . At the inquest, the evidence from the pathologist showed that Mr. Jackson had in his blood at the time of death, more than twice the level of caffeine that can produce a fatality and around 50 times the level that would be found normally in someone drinking tea and coffee.
a) There was at the time little information available as to the level of caffeine in this product and the dangers of consuming large amounts of caffeine ,
b) The product seems to me to sit uncomfortably in a gap between medication and sweets, when any person treating the product simply as sweets maybe in danger. I acknowledge of course, that part of the answer is public awareness and I trust that the publicity that was given to this case may assist in that regard.
” Open source report
14 Oct 2013 Frederick Davidson · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 9 Delays in medical treatment following pneumothorax View source Failure to recognise pneumothorax on X-rays View source Inadequate recording of nasogastric tube placement View source Feeding via nasogastric tube before completion of full checks View source Failure to record nasogastric tube feeding authorisation View source Inappropriate use of nasogastric tubes for patients with advanced dementia and seizures View source Unexplained gaps in clinical notes View source Delays in forwarding and receiving X-ray reports from radiology View source Breakdown in communication between junior doctors and consultants View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Frederick Davidson · 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
Frederick Davidson was admitted to Epsom General Hospital with aspiration pneumonia after recurrent seizures and later died following a pneumothorax caused by an unnoticed and incorrectly placed nasogastric tube. Concerns included inadequate documentation and communication, the use and checking of the tube, delayed recognition and treatment of the pneumothorax, and delays in radiology reporting.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in medical treatment following pneumothorax
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment .
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise pneumothorax on X-rays
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 recording of nasogastric tube placement
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Feeding via nasogastric tube before completion of full checks
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to record nasogastric tube feeding authorisation
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inappropriate use of nasogastric tubes for patients with advanced dementia and seizures
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unexplained gaps in clinical notes
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 forwarding and receiving X-ray reports from radiology
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Breakdown in communication between junior doctors and consultants
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” Open source report
Concerns raised 3 Failure to detect breech presentation before delivery View source Lack of national consideration of the risks and benefits of routine late-pregnancy scanning View source Lack of national guidelines on routine late-pregnancy scanning for breech presentation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Leo Deady · 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
Leo Deady died at Queen Elizabeth Hospital at one hour of age following an undiagnosed breech presentation, which was first noticed when the mother was fully dilated. The report raised concerns about missed breech presentations, the risks of vaginal breech delivery, and the absence of national guidance on routine late-pregnancy scanning to detect breech presentation.
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 detect breech presentation before delivery
Wider context from the report “(1) The evidence given at the inquest was that there is a small but significant rate of breech presentation nationally and that a significant proportion of breech presentations go undiagnosed . The percentage of undiagnosed breech presentations may be as high as 25%. The risks of vaginal breech delivery are very high.
Although midwives (especially experienced midwives as in this case) pick up most cases of breech presentation, it is clear that a small but significant number are missed .
The only certain way of detecting breech presentation is by scan . The evidence in this case was that there are no national guidelines as to whether hospitals should routinely scan at a late stage of pregnancy to exclude breech. The evidence at this inquest was that some London hospitals do carry out routine scanning in late pregnancy.
There was no evidence available at the inquest to say whether the risks and benefits of routine scanning in late pregnancy has been considered nationally in the light of potential funding issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 consideration of the risks and benefits of routine late-pregnancy scanning
Wider context from the report “(1) The evidence given at the inquest was that there is a small but significant rate of breech presentation nationally and that a significant proportion of breech presentations go undiagnosed. The percentage of undiagnosed breech presentations may be as high as 25%. The risks of vaginal breech delivery are very high.
Although midwives (especially experienced midwives as in this case) pick up most cases of breech presentation, it is clear that a small but significant number are missed.
The only certain way of detecting breech presentation is by scan. The evidence in this case was that there are no national guidelines as to whether hospitals should routinely scan at a late stage of pregnancy to exclude breech. The evidence at this inquest was that some London hospitals do carry out routine scanning in late pregnancy.
There was no evidence available at the inquest to say whether the risks and benefits of routine scanning in late pregnancy has been considered nationally in the light of potential funding issues .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidelines on routine late-pregnancy scanning for breech presentation
Wider context from the report “(1) The evidence given at the inquest was that there is a small but significant rate of breech presentation nationally and that a significant proportion of breech presentations go undiagnosed. The percentage of undiagnosed breech presentations may be as high as 25%. The risks of vaginal breech delivery are very high.
Although midwives (especially experienced midwives as in this case) pick up most cases of breech presentation, it is clear that a small but significant number are missed.
The only certain way of detecting breech presentation is by scan. The evidence in this case was that there are no national guidelines as to whether hospitals should routinely scan at a late stage of pregnancy to exclude breech . The evidence at this inquest was that some London hospitals do carry out routine scanning in late pregnancy.
There was no evidence available at the inquest to say whether the risks and benefits of routine scanning in late pregnancy has been considered nationally in the light of potential funding issues.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Routine national late-pregnancy scanning is not considered beneficial based on existing evidence, so developing a national system is unnecessary.
Verbatim wording from the response “In October 2008, the Cochrane Review into The Routine ultrasound in late pregnancy (after 24 weeks’ gestation) concluded that, based on existing evidence, routine late pregnancy ultrasound in low-risk or unselected populations does not confer benefit on mother or baby.” Source location 2013-0369-Response-by-Department-of-Health
Open published response
Concerns raised 4 Failure to contact a consultant when Early Warning Scores indicate clinical deterioration View source Failure to refer patients to consultant level when Early Warning Scores indicate escalation View source Failure to calculate Early Warning Scores accurately View source Lack of a single standardised Early Warning Score calculation system 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
Jude Augustus Gordon · 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
Jude Augustus Gordon underwent surgery and anaesthesia on 23 November 2011, deteriorated with signs of respiratory failure on 27 November, and died shortly after suffering a cardiac arrest. The concerns included failure to escalate his treatment or refer him to critical care, miscalculation of the Early Warning Score, variation in how scores were calculated between Trusts, and the absence of an automatic alert system for senior clinicians.
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 contact a consultant when Early Warning Scores indicate clinical deterioration
Wider context from the report “(2) Evidence was given at the inquest, by a consultant, that if he had been called to see Mr Gordon at the time his condition deteriorated, as was indicated by the Early Warning Score system should have happened , then he would have referred to critical care. He was not contacted . I was informed at the inquest that a Trust in Birmingham has a computerised system, that leads to an automatic alert to the relevant senior doctor on each occasion that a Early Warning Score exceeds the relevant level, for contact to be required. Such a system would on the 27th November 2011, to the consultant attending on Mr Gordon.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 consultant level when Early Warning Scores indicate escalation
Wider context from the report “(1) As stated the Early Warning Score in Sheffield is referred to as SHEWS. It was clear from the evidence that for a period of almost four and a half hours, prior to his final collapse, Mr Gordon’s score had shown a marked increase. This in itself should have led to referral to consultant level which did not happen . It was also apparent that there had been a miscalculation of the Early Warning Score, by more than one individual. The court was informed, by expert evidence, that there are differences in the method of calculating an Early Warning Score, between different Trusts. Nursing staff, but in particular junior doctors, who are often the person to make the decision to increase the level of treatment, have either trained or worked in different Trusts. This may lead to confusion. It was not clear to me why there is not a single, National, Early Warning Score system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to calculate Early Warning Scores accurately
Wider context from the report “(1) As stated the Early Warning Score in Sheffield is referred to as SHEWS. It was clear from the evidence that for a period of almost four and a half hours, prior to his final collapse, Mr Gordon’s score had shown a marked increase. This in itself should have led to referral to consultant level which did not happen. It was also apparent that there had been a miscalculation of the Early Warning Score, by more than one individual . The court was informed, by expert evidence, that there are differences in the method of calculating an Early Warning Score, between different Trusts. Nursing staff, but in particular junior doctors, who are often the person to make the decision to increase the level of treatment, have either trained or worked in different Trusts. This may lead to confusion. It was not clear to me why there is not a single, National, Early Warning Score system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a single standardised Early Warning Score calculation system
Wider context from the report “(1) As stated the Early Warning Score in Sheffield is referred to as SHEWS. It was clear from the evidence that for a period of almost four and a half hours, prior to his final collapse, Mr Gordon’s score had shown a marked increase. This in itself should have led to referral to consultant level which did not happen. It was also apparent that there had been a miscalculation of the Early Warning Score, by more than one individual. The court was informed, by expert evidence, that there are differences in the method of calculating an Early Warning Score, between different Trusts . Nursing staff, but in particular junior doctors, who are often the person to make the decision to increase the level of treatment, have either trained or worked in different Trusts. This may lead to confusion . It was not clear to me why there is not a single, National, Early Warning Score system .
” Open source report
Concerns raised 3 Lack of clear national guidance and routing for independent providers to pre-alert hospitals and place them on standby View source Lack of ambulance crew access to coded hospital entrance keypads View source Failure to maintain continuous staffing of resuscitation receptions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Martin Daffydd Barker · 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
Martin Daffydd Barker became unwell after taking MDMA at a large event on 9 December 2012 and was transported to Salford Royal Hospital, where he was pronounced deceased; his cause of death was confirmed as MDMA toxicity. Concerns included the absence of clear guidance for independent medical providers to pre-alert hospitals about critically ill incoming patients, resulting in the hospital not being prepared for his arrival, and difficulties accessing the resuscitation unit overnight.
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 clear national guidance and routing for independent providers to pre-alert hospitals and place them on standby
Wider context from the report “1. There appears to be no national guidance on how independent national providers of medical services (particularly those covering large scale public events) can put NHS hospitals on standby for incoming urgent patients , something which is normal procedure for the regional ambulance services.
2. There is confusion as to whether the independent providers should place a call to the regional ambulance services who would then act as “gatekeeper” in forwarding this information to the respective hospital.
3. Without clear guidance there is a risk that the most critically ill people who are being transported to hospital are at risk as the hospitals have received no pre-alert, have not had the opportunity to place teams on standby and are not expecting their arrival .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 ambulance crew access to coded hospital entrance keypads
Wider context from the report “4. In certain hospitals at particular times i.e. overnight this problem is exacerbated by the fact that the resus reception is not manned constantly and this may cause delays in ambulance crew gaining access especially if the entrance has a coded key pad which they also do not have access to .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain continuous staffing of resuscitation receptions
Wider context from the report “4. In certain hospitals at particular times i.e. overnight this problem is exacerbated by the fact that the resus reception is not manned constantly and this may cause delays in ambulance crew gaining access especially if the entrance has a coded key pad which they also do not have access to.
” 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 Share the case with the Care Quality Commission for consideration of emergency-department access arrangements in independent ambulance-service inspections.
Verbatim wording from the response “As you will appreciate, independent providers of ambulance services do not fall directly within the remit of the Department of Health. They are however required to register with, and be inspected by, the Care Quality Commission. I therefore propose to share this case with the CQC so that they can consider whether adequate arrangements for access to emergency departments need to be part of the inspection portfolio for such organisations. Patients might reasonably expect independent ambulance providers to have in place arrangements to access emergency departments to which they might be required to take patients, and that reasonable access should be granted.” Source location 2013-0226-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 Write to the Health and Safety Executive to bring the case to its attention regarding independent ambulance-service access to receiving emergency departments.
Verbatim wording from the response “I therefore intend to write to the HSE to bring this case to their attention. Responsibility for licensing, including arrangements for medical cover at events, sits with local authorities. It should, for example, be possible for HSE to amend the Purple Guide to indicate more explicitly the arrangements that need to be in place for independent ambulance services to contact and access receiving emergency departments. It may be reasonable that local authorities should satisfy themselves that this has been adequately addressed before granting an application. However this would ultimately be a matter for the HSE to decide.” Source location 2013-0226-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 Licensing and medical-cover arrangements at public events are the responsibility of local authorities.
Verbatim wording from the response “I therefore intend to write to the HSE to bring this case to their attention. Responsibility for licensing, including arrangements for medical cover at events, sits with local authorities. It should, for example, be possible for HSE to amend the Purple Guide to indicate more explicitly the arrangements that need to be in place for independent ambulance services to contact and access receiving emergency departments. It may be reasonable that local authorities should satisfy themselves that this has been adequately addressed before granting an application. However this would ultimately be a matter for the HSE to decide.” Source location 2013-0226-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 meetings among the ambulance provider, receiving Trust and ambulance service are considered sufficient to prevent a similar incident.
Verbatim wording from the response “I am satisfied that meetings and discussions that have taken place locally involving Manchester Medical Services, Salford Royal NHS Foundation Trust and the North West Ambulance Service, as set out in their responses to you, will help to ensure that a similar situation does not arise again with these organisations.” Source location 2013-0226-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amending the Purple Guide to specify independent ambulance access arrangements is ultimately for the HSE to decide.
Verbatim wording from the response “I therefore intend to write to the HSE to bring this case to their attention. Responsibility for licensing, including arrangements for medical cover at events, sits with local authorities. It should, for example, be possible for HSE to amend the Purple Guide to indicate more explicitly the arrangements that need to be in place for independent ambulance services to contact and access receiving emergency departments. It may be reasonable that local authorities should satisfy themselves that this has been adequately addressed before granting an application. However this would ultimately be a matter for the HSE to decide.” Source location 2013-0226-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Independent ambulance providers do not fall directly within the Department of Health’s remit.
Verbatim wording from the response “As you will appreciate, independent providers of ambulance services do not fall directly within the remit of the Department of Health. They are however required to register with, and be inspected by, the Care Quality Commission. I therefore propose to share this case with the CQC so that they can consider whether adequate arrangements for access to emergency departments need to be part of the inspection portfolio for such organisations. Patients might reasonably expect independent ambulance providers to have in place arrangements to access emergency departments to which they might be required to take patients, and that reasonable access should be granted.” Source location 2013-0226-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