Concerns raised 3 Absence of a robust system for providing arteriovenous fistula patients with clear information about risks and complications View source Lack of consistency in information between areas when healthcare practitioners transfer jobs View source Inconsistency in information provided to arteriovenous fistula patients 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
John Michael Bailey · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Michael Bailey died from a cardiac arrest on 6 September 2013. The report raised concerns about the absence of a robust system for providing patients with arteriovenous fistulas with clear information about risks and complications, and about inconsistencies in information provided by different sources.
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 Absence of a robust system for providing arteriovenous fistula patients with clear information about risks and complications
Wider context from the report “(1) The absence of a robust system to ensure that patients who have an arteriovenous fistula are provided with clear information about the risks and complications , however the following may be worthy of consideration:
1. The National Care Quality Commission? is the management of that drug between the Trust and the management of Arteriovenous fistula? The specifics of that Protocol are alleged to be unclear.
1.1. The guideline for dealing with patients with Arteriovenous fistulas, management of Arteriovenous fistulas and secondary care physicians.
1.2. The protocol on the risk of the fistula? which should be carried out at each [████████].
1.3. The protocol provided to patients may extend the period.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 consistency in information between areas when healthcare practitioners transfer jobs
Wider context from the report “(3) Is it possible that a lack of consistency between different areas may also give rise to a risk where health care practitioners transfer jobs between those areas .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistency in information provided to arteriovenous fistula patients
Wider context from the report “(2) There was also inconsistency between the information provided by [████████] and [████████]. This inconsistency resulted in the circumstances of this case.
” Open source report
Concerns raised 6 Failure to prevent patients at risk of self-harm from being left alone View source Failure to arrange follow-up assessment of the effect of medication with an increased risk of self-harm View source Lack of structured assessment and recording of self-harm risk factors View source Confusion about confidentiality when providing safety supervision for patients at risk of self-harm View source Use of unhelpful high, medium and low risk categories in self-harm risk assessment View source Failure to consult patients before first prescribing medication with an increased risk of self-harm View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Roshen Abbas Ladak-Ebrahim · 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
Roshen Abbas Ladak-Ebrahim, aged 22, was found having hanged himself at home on the evening of 11 October 2012. The report raised concerns about assessing and recording immediate risk of self-harm, ensuring patients at risk were not left alone, and requiring appropriate medical consultation and follow-up when prescribing medication associated with increased self-harm risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent patients at risk of self-harm from being left alone
Wider context from the report “Consideration to be given to giving guidance to health care professionals on the steps that should be taken to ensure that a patient is kept safe by those looking after the patient. In particular informing those looking after a patient that the patient should not be left alone where there is a concern that the patient is at risk of harming themselves . Evidence heard at the inquest suggested that there was some confusion over whether this advice would breach a patient's confidentiality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 arrange follow-up assessment of the effect of medication with an increased risk of self-harm
Wider context from the report “Consideration to be given to guidance whereby a doctor working in the community mental health agencies is required to have a consultation with a patient before prescribing medication that carries an increased risk of self-harm when first prescribed and arranges to see the patient again to assess the effect of the medication .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 structured assessment and recording of self-harm risk factors
Wider context from the report “Consideration to be given to issuing guidance when assessing risk of self-harm. The suggestion at the inquest was to firstly assess and record whether there is an immediate risk of self-harm . If there is no immediate risk of self-harm then the assessment should focus on whether there are any thoughts of self-harm, (recording frequency, duration, intensity etc). Whether there is a plan, (recording the details of the plan or plans, etc) and whether there is an intention to end life. Whether the individual is vulnerable to acting on impulse and any past history . The use of high, medium and low risk were considered unhelpful when assessing risk of self-harm.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Confusion about confidentiality when providing safety supervision for patients at risk of self-harm
Wider context from the report “Consideration to be given to giving guidance to health care professionals on the steps that should be taken to ensure that a patient is kept safe by those looking after the patient. In particular informing those looking after a patient that the patient should not be left alone where there is a concern that the patient is at risk of harming themselves. Evidence heard at the inquest suggested that there was some confusion over whether this advice would breach a patient's confidentiality .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Use of unhelpful high, medium and low risk categories in self-harm risk assessment
Wider context from the report “Consideration to be given to issuing guidance when assessing risk of self-harm. The suggestion at the inquest was to firstly assess and record whether there is an immediate risk of self-harm. If there is no immediate risk of self-harm then the assessment should focus on whether there are any thoughts of self-harm, (recording frequency, duration, intensity etc). Whether there is a plan, (recording the details of the plan or plans, etc) and whether there is an intention to end life. Whether the individual is vulnerable to acting on impulse and any past history. The use of high, medium and low risk were considered unhelpful when assessing risk of self-harm.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 consult patients before first prescribing medication with an increased risk of self-harm
Wider context from the report “Consideration to be given to guidance whereby a doctor working in the community mental health agencies is required to have a consultation with a patient before prescribing medication that carries an increased risk of self-harm when first prescribed and arranges to see the patient again to assess the effect of the medication.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish supplementary guidance clarifying when confidential information may be disclosed in the public interest.
Verbatim wording from the response “In addition, the Department of Health published supplementary guidance to the NHS Confidentiality Code of Practice (November 2010, Ref 13912) on disclosing confidential information when there is a public interest justification to do so and makes clear to healthcare professionals when it is appropriate to disclose personal information.” Source location 2013-0287-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a consensus statement promoting information sharing to help prevent suicide, within the relevant law.
Verbatim wording from the response “Turning to confidentiality, there are clearly times when health care professionals, in dealing with a person at risk of suicide, may need to inform the family about aspects of risk to help keep the patient safe. I agree it is crucial that we address any confusion about how information can be shared. That is why the Department of Health is already working with Royal Colleges and professional organisations to agree a consensus statement designed to promote greater sharing of information with the aim of preventing suicide, within the context of the relevant law. We published this on 17 January at:” Source location 2013-0287-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing NICE clinical guidelines sufficiently address assessing immediate self-harm and suicide risk.
Verbatim wording from the response “Taking your points in turn: guidance on risk assessment is included in clinical guidelines (CG133 Self-harm: longer-term management) produced by the National Institute for Health and Clinical Excellence (NICE), and issued in November 2011. It is worth quoting a relevant extract. The guidelines state:” Source location 2013-0287-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