4 Aug 2025 Tracey Ostler · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 13 Unclear legal authority for preventing psychiatric patients leaving the emergency department View source Unavailability of appropriately trained mental health nurses for acute psychiatric patients View source Unclear ultimate clinical responsibility for psychiatric patients in the emergency department View source Compromised emergency department capacity to meet physically ill patients' needs View source Failure to provide appropriate multidisciplinary psychiatric ward-based care View source Lack of psychiatric hospital beds resulting in prolonged emergency department detention View source Failure to undertake thorough mental capacity assessments for life-threatening treatment decisions View source Failure to provide lawful Mental Health Act detention safeguards and Responsible Clinician oversight View source Inadequate paramedic training for mental capacity assessments View source Inadequate and unavailable protocol for capacity assessments in life-threatening circumstances View source Lack of a system for joint ambulance and mental health emergency plans View source Failure to provide frontline paramedics with vital mental health risk and capacity information View source Unsuitable emergency department environment for psychiatric patients View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tracey Ostler · 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
Tracey Ostler, who had severe Emotionally Unstable Personality Disorder and a history of self-harm and overdoses, took an overdose and cut her wrists on 12 June 2023. After paramedics attended her home on 16 June following a further overdose, they left her there after deciding she had capacity to refuse hospital treatment; she was later found unconscious and died in hospital on 18 June 2023. The principal concerns were inadequate capacity assessment and clinical consultation, failures to share information and coordinate mental-health and ambulance care, the absence of multi-agency safety planning, and insufficient psychiatric hospital beds.
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 Unclear legal authority for preventing psychiatric patients leaving the emergency department
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 appropriately trained mental health nurses for acute psychiatric patients
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them . This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients .
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unclear ultimate clinical responsibility for psychiatric patients in the emergency department
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient .
” 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 Compromised emergency department capacity to meet physically ill patients' needs
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate multidisciplinary psychiatric ward-based care
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team .
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 psychiatric hospital beds resulting in prolonged emergency department detention
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds . The longest wait by such a patient in these circumstances has been 6 weeks . There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed .
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 undertake thorough mental capacity assessments for life-threatening treatment decisions
Wider context from the report “Training for Paramedics to undertake Capacity Assessments.
Addressed to the Health and Care Professionals Council and South East Coast Ambulance Service
3. I found that the paramedics who attended Ms Ostler on the 16th June 2023, and assessed her capacity to refuse lifesaving treatment after taking a serious paracetamol overdose, failed to undertake a thorough capacity assessment . In particular, they failed to assess adequately whether she had the ability to weigh up the information being given to her .
4. Ms Ostler was recorded in written evidence provided by the more senior attending paramedic who attended as saying that she would not discuss why she wanted to die. A more senior paramedic, who reviewed that evidence for the purposes of the inquest, regarded the written evidence as demonstrating that the capacity assessment had been undertaken appropriately.
5. Neither the attending paramedic nor the reviewing paramedic appreciated that unless the patient was able to tell them why she had decided that she wanted to die, that she had not demonstrated to them how she had weighed up the information available to her. Therefore, a full capacity assessment could not be completed.
6. I am concerned that the training they had received, both whilst students and subsequently, had not been adequate to equip them to undertake adequate capacity assessments.
” 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 lawful Mental Health Act detention safeguards and Responsible Clinician oversight
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department . There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983 . In addition, they do not have a Responsible Clinician .
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 paramedic training for mental capacity assessments
Wider context from the report “Training for Paramedics to undertake Capacity Assessments.
Addressed to the Health and Care Professionals Council and South East Coast Ambulance Service
3. I found that the paramedics who attended Ms Ostler on the 16th June 2023, and assessed her capacity to refuse lifesaving treatment after taking a serious paracetamol overdose, failed to undertake a thorough capacity assessment. In particular, they failed to assess adequately whether she had the ability to weigh up the information being given to her.
4. Ms Ostler was recorded in written evidence provided by the more senior attending paramedic who attended as saying that she would not discuss why she wanted to die. A more senior paramedic, who reviewed that evidence for the purposes of the inquest, regarded the written evidence as demonstrating that the capacity assessment had been undertaken appropriately.
5. Neither the attending paramedic nor the reviewing paramedic appreciated that unless the patient was able to tell them why she had decided that she wanted to die, that she had not demonstrated to them how she had weighed up the information available to her. Therefore, a full capacity assessment could not be completed.
6. I am concerned that the training they had received, both whilst students and subsequently, had not been adequate to equip them to undertake adequate capacity assessments.
” 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 and unavailable protocol for capacity assessments in life-threatening circumstances
Wider context from the report “South East Coast Ambulance Service’s protocol on undertaking capacity assessments in relation to life threatening decisions.
Addressed to the South East Coast Ambulance Service
7. The Trusts policy on Mental Capacity is being reviewed to improve articulation of how to assess mental capacity in life threatening circumstances. It is not yet available . I regarded the current policy as inadequate and remain concerned about this because I have not been able to review the revised document.
” 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 for joint ambulance and mental health emergency plans
Wider context from the report “Multi Agency Safeguarding Plans
Addressed to the Surrey and Borders Partnership Trust and South East Coast Ambulance Service
8. Ms Ostler suffered from a severe Emotionally Unstable Personality Disorder, this was a longstanding diagnosis, and the effects were well known to her mental health team. She was placed in the community on a Positive Risk Taking Plan. She presented a continuous and serious risk to herself in the community and was prone to impulsive acts of self harm. Ambulances were frequently required to attend her home after such acts. The disorder impacted her ability to make capacious decisions about her own care.
9. The independent expert consultant psychiatrist called at the inquest regarded it as good practice in these circumstances to have a joint plan in place, including liaison between the ambulance service and mental health teams, for dealing with emergencies .
10. No system currently exists in Surrey to create such plans.
11. The paramedics who attended Ms Ostler on the 16th June 2023 did not know she had a diagnosis of Emotionally Unstable Personality Disorder, nor that this such a diagnosis would be likely to affect her decision-making capacity because it made her more prone to be volatile and impulsive.
12. The psychiatric evidence was that she would be likely to lack capacity.
13. Paramedics assessing her lacked this vital information. In consequence, she was left at home to die.
14. I have not been provided with any Protocol between the services to ensure safety planning in these circumstances that would ensure that front line paramedics are made aware that they are dealing with a seriously unwell mental health patients who is at high risk living in the community.
15. I therefore remain concerned that such a death could occur again.
” 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 frontline paramedics with vital mental health risk and capacity information
Wider context from the report “Multi Agency Safeguarding Plans
Addressed to the Surrey and Borders Partnership Trust and South East Coast Ambulance Service
8. Ms Ostler suffered from a severe Emotionally Unstable Personality Disorder, this was a longstanding diagnosis, and the effects were well known to her mental health team. She was placed in the community on a Positive Risk Taking Plan. She presented a continuous and serious risk to herself in the community and was prone to impulsive acts of self harm. Ambulances were frequently required to attend her home after such acts. The disorder impacted her ability to make capacious decisions about her own care.
9. The independent expert consultant psychiatrist called at the inquest regarded it as good practice in these circumstances to have a joint plan in place, including liaison between the ambulance service and mental health teams, for dealing with emergencies.
10. No system currently exists in Surrey to create such plans.
11. The paramedics who attended Ms Ostler on the 16th June 2023 did not know she had a diagnosis of Emotionally Unstable Personality Disorder , nor that this such a diagnosis would be likely to affect her decision-making capacity because it made her more prone to be volatile and impulsive.
12. The psychiatric evidence was that she would be likely to lack capacity.
13. Paramedics assessing her lacked this vital information. In consequence, she was left at home to die.
14. I have not been provided with any Protocol between the services to ensure safety planning in these circumstances that would ensure that front line paramedics are made aware that they are dealing with a seriously unwell mental health patients who is at high risk living in the community.
15. I therefore remain concerned that such a death could occur again.
” 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 Unsuitable emergency department environment for psychiatric patients
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 Provide further guidance on the legal framework and handover protocol in the next revision of the Mental Health Act Code of Practice.
Verbatim wording from the response “We accept that there may be a need to provide greater clarity on what powers are available to health professionals to hold someone in A&E, until an assessment can be completed. We will engage further to understand how the current legal framework is applied and identify solutions to the problems raised. We will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice.” Source location Response from Department for Health and Social Care
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 Continue stakeholder work to consider support for people experiencing mental health crisis in A&E and improve community-based alternatives.
Verbatim wording from the response “We will also continue to work closely with stakeholders to consider how we can support those experiencing a mental health crisis in A&E, as well as wider actions to improve care to prevent people reaching crisis point or, where they do, creating better community-based alternatives to A&E.” Source location Response from Department for Health and Social Care
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 Provide 24-hour NHS 111 mental health crisis access with trained professional assessment and routes to community support or alternative crisis services.
Verbatim wording from the response “Anyone in England experiencing a mental health crisis can now speak to a trained NHS professional at any time of the day through a ‘mental health’ option on NHS 111. Trained NHS staff will assess patients over the phone and guide callers with next steps such as organising face-to-face community support or facilitating access to alternatives services, such as crisis cafés or safe havens which provide a place for people to stay as an alternative to Accident and Emergency (A&E) or a hospital admission.” Source location Response from Department for Health and Social Care
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 Increase the number of mental health emergency departments to around 85, providing short-term intensive crisis support as an alternative to A&E.
Verbatim wording from the response “This includes increasing the number of mental health emergency departments to around 85, which will provide reactive, short term intensive support for people in acute mental health crisis as an alternative to A&E.” Source location Response from Department for Health and Social Care
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 Engage stakeholders to clarify how the current legal framework applies to holding patients in A&E and identify solutions to the reported problems.
Verbatim wording from the response “We accept that there may be a need to provide greater clarity on what powers are available to health professionals to hold someone in A&E, until an assessment can be completed. We will engage further to understand how the current legal framework is applied and identify solutions to the problems raised. We will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice.” Source location Response from Department for Health and Social Care
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 Deliver more mental health crisis care in communities through new care models, including 24/7 neighbourhood mental health centres integrating crisis and community services with short-stay beds.
Verbatim wording from the response “As part of our 10 Year Health Plan, we will make sure more mental health crisis care is delivered in the community, close to people’s homes, through new models of care and support, so that fewer people need to go into hospital. This includes transforming mental health services into 24/7 neighbourhood mental health centres, which will bring together a range of community mental health services under one roof, including crisis services, community mental health services and short-stay beds.” Source location Response from Department for Health and Social Care
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 Transform mental health crisis care into community-based 24/7 neighbourhood mental health centres with integrated crisis services, community services and short-stay beds.
Verbatim wording from the response “As part of our 10 Year Health Plan, we will make sure more mental health crisis care is delivered in the community, close to people’s homes, through new models of care and support, so that fewer people need to go into hospital. This includes transforming mental health services into 24/7 neighbourhood mental health centres, which will bring together a range of community mental health services under one roof, including crisis services, community mental health services and short-stay beds.” Source location Response from Department for Health and Social Care
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 Engage further to understand application of the current legal framework and identify solutions to unlawful detention risks in A&E.
Verbatim wording from the response “We accept that there may be a need to provide greater clarity on what powers are available to health professionals to hold someone in A&E, until an assessment can be completed. We will engage further to understand how the current legal framework is applied and identify solutions to the problems raised. We will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice.” Source location Response from Department for Health and Social Care
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 Provide 24-hour access to trained NHS professionals through the NHS 111 mental health option, with assessment and onward access to community or alternative crisis services.
Verbatim wording from the response “Anyone in England experiencing a mental health crisis can now speak to a trained NHS professional at any time of the day through a ‘mental health’ option on NHS 111. Trained NHS staff will assess patients over the phone and guide callers with next steps such as organising face-to-face community support or facilitating access to alternatives services, such as crisis cafés or safe havens which provide a place for people to stay as an alternative to Accident and Emergency (A&E) or a hospital admission.” Source location Response from Department for Health and Social Care
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 Provide further guidance on the legal framework and health-police handover protocol in the next revision of the Mental Health Act Code of Practice.
Verbatim wording from the response “We accept that there may be a need to provide greater clarity on what powers are available to health professionals to hold someone in A&E, until an assessment can be completed. We will engage further to understand how the current legal framework is applied and identify solutions to the problems raised. We will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice.” Source location Response from Department for Health and Social Care
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 Increase the number of mental health emergency departments to around 85, providing short-term intensive crisis support as an alternative to A&E.
Verbatim wording from the response “This includes increasing the number of mental health emergency departments to around 85, which will provide reactive, short term intensive support for people in acute mental health crisis as an alternative to A&E.” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual trusts and local health systems are responsible for assessing and managing local psychiatric bed capacity.
Verbatim wording from the response “We expect individual trusts and local health systems to effectively assess and manage local bed capacity through the ‘flow’ of patients being discharged or moving to another setting.” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual trusts and local health systems are responsible for assessing and managing local psychiatric bed capacity.
Verbatim wording from the response “We expect individual trusts and local health systems to effectively assess and manage local bed capacity through the ‘flow’ of patients being discharged or moving to another setting.” Source location Response from Department for Health and Social Care
Open published response
Concerns raised 3 Failure to obtain psychiatrist review before discharge View source Discharge decisions falling to a senior psychiatric nurse View source Failure to account for recent self-harm, suicidal behaviour or suicidal thoughts when presentation appears improved 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
Sidi Chax Bojang · 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 19 July 2024, Sidi Chax Bojang left the platform at Oakleigh Park Railway Station and was struck by a fast train. He had recently attended hospital after reporting self-harm and experiencing a “wooshing” sound and flashes of light, and had called an ambulance on the morning of his death after cutting himself. The concerns included that possible serious mental illness and hallucinations were not recognised, that a psychiatrist did not review him before discharge, and that discharge was left to a senior psychiatric nurse.
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 obtain psychiatrist review before discharge
Wider context from the report “Where there is a significant change in presentation when assessed suggesting that the patient is now well, when either the same day, or a short time before presentation, acts of self harm, suicidal behaviour or thoughts were present.
That a psychiatrist did not review the person presenting before discharge .
The discharge of the person in these circumstances fell to a senior psychiatric nurse.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Discharge decisions falling to a senior psychiatric nurse
Wider context from the report “Where there is a significant change in presentation when assessed suggesting that the patient is now well, when either the same day, or a short time before presentation, acts of self harm, suicidal behaviour or thoughts were present.
That a psychiatrist did not review the person presenting before discharge.
The discharge of the person in these circumstances fell to a senior psychiatric nurse .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to account for recent self-harm, suicidal behaviour or suicidal thoughts when presentation appears improved
Wider context from the report “Where there is a significant change in presentation when assessed suggesting that the patient is now well , when either the same day, or a short time before presentation, acts of self harm, suicidal behaviour or thoughts were present .
That a psychiatrist did not review the person presenting before discharge.
The discharge of the person in these circumstances fell to a senior psychiatric nurse.
” Open source report
29 Jul 2025 Leslie Thompson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Unavailability of core physiotherapy services during evenings and weekends View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Leslie 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
Leslie Thompson died at Tameside General Hospital on 20 February 2025 following a fall in hospital, which caused a head injury against a background of chronic subdural haematoma and multiple complex health problems. The concern was that he had been assessed as medically fit for discharge but was awaiting physiotherapy, with limited evening and weekend physiotherapy services potentially causing discharge delays and exposing patients to risks associated with remaining in an acute hospital environment.
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 core physiotherapy services during evenings and weekends
Wider context from the report “At inquest, the court heard evidence that this hospital (in common with many others) does not have core physiotherapy services operating at evenings and weekends . I am concerned as to the effects of this in terms of delays to discharge, and the resultant exposure to risk of patients for whom an acute hospital environment is not most suitable.
” 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 Reform the Better Care Fund from 2026/27 to establish consistent joint NHS and local-authority funding for essential integrated care services.
Verbatim wording from the response “Furthermore, the Better Care Fund (BCF) is a key part of our plan to address discharge delays, especially where they are caused by a lack of a necessary service such as physiotherapy. The BCF supports Integrated Care Boards and local authorities to deliver joined-up health and social care, and this year, the BCF will provide £9 billion to help ensure patients receive appropriate and timely care in the right place, with shared accountability for discharge planning. Starting in the financial year 2026/27, we will reform the BCF to ensure consistent joint NHS and local authority funding for those services that are essential for integrated health and social care, such as hospital discharge, intermediate care, rehabilitation and reablement.” Source location Response from Department of Health and Social Care
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 Provide £9 billion through the Better Care Fund to support timely, joined-up health and social care, including discharge-related services.
Verbatim wording from the response “Furthermore, the Better Care Fund (BCF) is a key part of our plan to address discharge delays, especially where they are caused by a lack of a necessary service such as physiotherapy. The BCF supports Integrated Care Boards and local authorities to deliver joined-up health and social care, and this year, the BCF will provide £9 billion to help ensure patients receive appropriate and timely care in the right place, with shared accountability for discharge planning. Starting in the financial year 2026/27, we will reform the BCF to ensure consistent joint NHS and local authority funding for those services that are essential for integrated health and social care, such as hospital discharge, intermediate care, rehabilitation and reablement.” Source location Response from Department of Health and Social Care
Open published response
29 Jul 2025 Azroy Dawes-Clarke · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 2 Failure to establish clear command and control arrangements during critical medical emergencies in custodial settings View source Failure to establish a communication strategy during critical medical emergencies in custodial settings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Azroy Dawes-Clarke · 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
Azroy Dawes-Clarke died in hospital after self-ligaturing in HMP Elmley, followed by restraint, cardiac and respiratory arrest, and further arrests during conveyance and hospital treatment. The principal concerns included confused communication and unclear command structures among prison staff, healthcare professionals and paramedics, disproportionate and prolonged restraint, delays in obtaining medical assistance and starting CPR, and inadequate consideration of his breathing and positioning.
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 establish clear command and control arrangements during critical medical emergencies in custodial settings
Wider context from the report “(1) As the jury noted, communication between attending prison staff, healthcare professionals and paramedics was confused. There was confusion as to who had command and control of the medical emergency, which public body took primacy and the difference in roles and responsibilities . Those attending the scene did not establish any sort of communication strategy or command structure . During prevention of future deaths evidence, there remained a lack of clarity and consistency as to how such a situation would be avoided if a critical medical emergency eventuated in a custodial setting again .
(2)
(3)
” 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 establish a communication strategy during critical medical emergencies in custodial settings
Wider context from the report “(1) As the jury noted, communication between attending prison staff, healthcare professionals and paramedics was confused . There was confusion as to who had command and control of the medical emergency, which public body took primacy and the difference in roles and responsibilities. Those attending the scene did not establish any sort of communication strategy or command structure. During prevention of future deaths evidence, there remained a lack of clarity and consistency as to how such a situation would be avoided if a critical medical emergency eventuated in a custodial setting again .
(2)
(3)
” 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 HM Prison and Probation Service is responsible for leadership, command and control of prison emergencies, including medical emergencies.
Verbatim wording from the response “I can confirm that HM Prison and Probation Service is the public body which takes primacy for the leadership, command and control of an emergency situation in prison, including a medical emergency. Healthcare staff within a prison should respond to and provide any emergency medical treatment, such as CPR, until a paramedic arrives on scene.” Source location Response from Department of Health and Social Care
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 Ambulance Service is expected to provide further detail about paramedics’ role in medical emergencies within prisons.
Verbatim wording from the response “I understand that you have issued a separate Regulation 28 report to the Director General Chief Executive of HM Prison and Probation Service; and one to the Governor at HMP Elmley, Oxleas NHS Foundation Trust and the South East Coast Ambulance Service. I would expect the Ambulance Service to provide more detail about the role of paramedics in medical emergencies within the prison estate.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 11 Lack of police training for mental health-related incidents involving illicit substance use View source Lack of cross-sector working and joint agency policy for Acute Behavioural Disorder/Disturbance View source Delays and non-attendance in EMAS ambulance response to s.136 conveyance requests View source Unavailability of mental health management, monitoring and treatment for people with co-occurring substance misuse who cannot abstain View source Failure within EMAS to ratify, disseminate and implement the relevant s.136 joint agency policy View source Failure of police training on ambulance conveyance for s.136 detainees View source Lack of police training on communicating s.136 detention decisions and reasons View source Lack of an out-of-hours local protocol for police access to mental health advice View source Lack of joined-up agency policy for s.136 detention and conveyance View source Reliance on unrealistic self-referral for people requiring mental health and substance misuse support View source Failure to align Street Triage Team capacity with current demand View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kaine Regan FLETCHER · 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
Kaine Regan FLETCHER, a 26-year-old man with paranoid personality disorder and a history of substance misuse, died on 3 July 2022 after restraint by police, developing rhabdomyolysis, multi-system organ failure and cardiac arrest. The report raises concerns about the lack of joined-up policies and cross-sector working on acute behavioural disturbance and section 136 detentions, police and ambulance conveyance practices and training, the availability of out-of-hours street triage, and gaps in services for people with combined mental health and substance misuse conditions.
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 police training for mental health-related incidents involving illicit substance use
Wider context from the report “4. Police training on s.136 MHA 1983 detention and mental health
I heard evidence that there is no national training for police officers on the correct wording to communicate a decision and the reasons for a s.136 detention to the detainee. Further, that there is no specific training in relation to persons who are struggling with their mental health and who may be under the influence of illicit substances . I am concerned that training in the area of mental health generally is lacking , which is impacting upon the approach of the police officers dealing with mental health related incidents.
” 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 cross-sector working and joint agency policy for Acute Behavioural Disorder/Disturbance
Wider context from the report “1. Lack of joint agency policy/cross-sector working on Acute Behavioural Disorder/Disturbance
In September 2022, the Royal College of Psychiatrists issued a position statement on Acute Behavioural Disturbance and Excited Delirium. The RCP recommend that:
• A cross-sector working group should be convened to develop an interim consensus on ‘ABD’, with active involvement of patients and carers, to agree terminology, key principles for professional guidance, and priorities for further research.
• This group should include representatives from police, custodial, ambulance, emergency medicine, mental health, and the judicial and coronial system. Support from relevant government departments would help ensure consistency across services.
• Further research should be urgently commissioned, including detailed investigation into how racial bias plays into the application of terminology such as ‘ABD’.
• Members of the cross-sector working group should collaborate on the development and delivery of training materials for staff working across public services
• All services should seek to improve standardised collection of disaggregated data on presentations and outcomes, and to conduct regular multi-disciplinary reviews to support high-quality research on this topic.
I have heard evidence that in Nottingham and Nottinghamshire, no such cross-sector working is in place or joint agency policy is in place . I have also heard evidence that there is no knowledge of such cross-sector working or joint agency policy in place within the East Midlands generally, or nationally. The consequence of this is that there is no joined up thinking, procedure or policy, between front-line services who are regularly dealing with cases of ABD . That lack of collaborative working between services gives rise to a risk of future death for persons who develop ABD both in the community or in custody. People at risk of developing ABD often also fall into categories of vulnerability, such as suffering with a mental health disorder or using illicit substances. To my mind, this increases the risk of future death in the absence of any collaboration. I am concerned that this appears to be a national issue.
” 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 non-attendance in EMAS ambulance response to s.136 conveyance requests
Wider context from the report “3. Police use of an ambulance as the mode of conveyance for s.136 detainees
I heard evidence that the correct mode of conveyance for persons detained under s.136 MHA 1983 is an ambulance, save in exceptional circumstances (e.g. where the detained person’s behaviour means it would be inappropriate, or where the wait for an ambulance would exceed 30 minutes).
I also heard evidence, that in the last 12 months an ambulance was called by the police in only 50% of s.136 detentions. Of that 50% in which an ambulance was called, an ambulance only attended on 50% of occasions (so 25% of the total detentions).
Of the nine police officers that gave evidence to me in this inquest on s.136 matters, none of them knew about the police policy on calling an ambulance to convey a s.136 detainee.
Two of the officers knew, anecdotally, that an ambulance was the preferred method of conveyance, but their evidence was that it was common for an ambulance to take well over 30 minutes or not turn up at all .
I am concerned that:
• There is a training issue within the police in relation to s.136 detentions and the correct mode of conveyance. Either officers do not know that they should call an ambulance, or they are ignoring their training/the instructions that they are given. This is born out in the statistics above.
• There is a response issue on the part of EMAS . This may, in part, be explained by the policy/service level agreement confusion within EMAS.
” 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 mental health management, monitoring and treatment for people with co-occurring substance misuse who cannot abstain
Wider context from the report “6. Mental Health Services – ‘the gap’
I am concerned that there is a ‘gap’ in mental health services for those people who have a dual diagnosis of a recognised mental health condition, combined with a substance misuse diagnosis . Clinically, I understand that substance misuse can provide a barrier to effective treatment of any mental health condition. However, I have heard evidence that there is no service available to patients for management, monitoring and treatment in circumstances where they are unable to abstain from substances but require care for the residual mental health condition . In circumstances where it is clinically recognised that substance misuse can exacerbate the symptoms of many mental health conditions, this gives risk to a clear risk of future death. The evidence that I have heard is that once treatment or referral options for these patients have been exhausted, they are discharged from the Local Mental Health Team with signposting to other services e.g. substance misuse services/charities or CRISIS. These services often required self-referral, which is not realistic for many people in these circumstances. Kaine fell into this gap, and I am concerned that there is a risk of future death for other patients if this gap is not filled. Again, it seems to me that this is an issue of national concern.
” 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 within EMAS to ratify, disseminate and implement the relevant s.136 joint agency policy
Wider context from the report “2. Lack of agreed joint agency policy between EMAS and the police on s.136 MHA 1983 detentions
I issued a PFD on 17 July 2025, part way through the final inquest hearing, to raise my concern over apparent confusion with both the police and EMAS as to the applicable joint agency policy dealing with s.136 MHA 1983 detention and conveyance.
Since that PFD was issued, the evidence has developed and the position at the end of the inquest was as follows:
• The police confirmed that the document titled “Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency sections 135 and 136 Mental Health Act 1983 Procedures” has been ratified within their organisation and continues to remain the relevant joint-agency policy for s.136 detention and conveyance. This policy has been implemented for the police since its inception.
• EMAS cannot confirm whether the above policy has been ratified in its current version within the organisation . They have confirmed that an employee at EMAS signed off on the 2021 version, but that this information was never disseminated within the organisation because the finalised version of the policy remained within that employee’s email inbox. The consequence appears to be that EMAS has never implemented this policy , rather they have been working to an internal policy for Mental Health Conveyance that contains different working standards.
Acknowledging that there is no confusion for the police as to the relevant policy, and that they do consider that it has been implemented, I remain concerned. My concerns can now properly be formulated as follows:
• There is no joined up thinking between agencies on the local policy for s.136 MHA 1983 detention and conveyance. For a policy to be effective, all purported parties to that policy need to know it applies to them.
• Internal disorganisation within EMAS has culminated in a situation where, even after a period of investigation between 17 July – 25 July, they are unable to tell the Court which, if any, joint agency policy applies to them. They are unable to tell the Court whether they are still part of the relevant working group. EMAS have allowed a situation to perpetuate in which they appear, on the face of the policy documents, to be party to an agreement (which includes service level agreements for conveyance) when they simply do not know if this is correct. The upshot of this is that other agencies may be placing reliance on the conveyance terms within the policy when they are dealing with s.136 detention.
My concerns are supported by the guidance available at ss. 16.30 – 16.35 of the Mental Health Code of Practice, which highlights the importance of local policy for s.136 detention. It does not appear that there is compliance with this guidance, published by the Department of Health.
The lack of joined up thinking between agencies locally gives rise to a risk of future death for persons detained under s.136 MHA 1983.
” 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 police training on ambulance conveyance for s.136 detainees
Wider context from the report “3. Police use of an ambulance as the mode of conveyance for s.136 detainees
I heard evidence that the correct mode of conveyance for persons detained under s.136 MHA 1983 is an ambulance, save in exceptional circumstances (e.g. where the detained person’s behaviour means it would be inappropriate, or where the wait for an ambulance would exceed 30 minutes).
I also heard evidence, that in the last 12 months an ambulance was called by the police in only 50% of s.136 detentions. Of that 50% in which an ambulance was called, an ambulance only attended on 50% of occasions (so 25% of the total detentions).
Of the nine police officers that gave evidence to me in this inquest on s.136 matters, none of them knew about the police policy on calling an ambulance to convey a s.136 detainee .
Two of the officers knew, anecdotally, that an ambulance was the preferred method of conveyance, but their evidence was that it was common for an ambulance to take well over 30 minutes or not turn up at all.
I am concerned that:
• There is a training issue within the police in relation to s.136 detentions and the correct mode of conveyance . Either officers do not know that they should call an ambulance, or they are ignoring their training/the instructions that they are given. This is born out in the statistics above.
• There is a response issue on the part of EMAS. This may, in part, be explained by the policy/service level agreement confusion within EMAS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of police training on communicating s.136 detention decisions and reasons
Wider context from the report “4. Police training on s.136 MHA 1983 detention and mental health
I heard evidence that there is no national training for police officers on the correct wording to communicate a decision and the reasons for a s.136 detention to the detainee . Further, that there is no specific training in relation to persons who are struggling with their mental health and who may be under the influence of illicit substances. I am concerned that training in the area of mental health generally is lacking, which is impacting upon the approach of the police officers dealing with mental health related incidents.
” 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 an out-of-hours local protocol for police access to mental health advice
Wider context from the report “5. The availability of the Street Triage Team
I heard evidence that Nottinghamshire is pioneering in its provision of a Street Triage Team, a service that has been available since 2014. This team is comprised of one police officer and one community psychiatric nurse who can travel to mental health incidents to provide assessment and advice to the response officers, particularly in relation to exercising s.136 powers.
I heard that this service is available between 8am and 1am, and that the resourcing of the service (both in terms of the shift patterns and the available cars) was determined by analysis of a data set in 2017.
At the time that the incident arose with Kaine on 3 July 2022, no STT was available as it was out of hours.
I am concerned that there is a need to review the data to ensure that the demand for the service in 2025 is still reflected in the shift patterns. I am concerned, based on the evidence that I heard from EMAS in relation to an increase of ~60% in mental health related calls, that the demand for service may have changed since 2017.
I note that the Mental Health Code of Practice includes the following guidance at [16.23] in relation to triage and s.136: “When deciding that detention may be necessary, the police may also benefit from seeking advice before using section 136 powers in cases where they are unsure that the circumstances are sufficiently serious for using these powers. Local protocols should set out how this advice can be provided and who the police should contact, including outside of normal business hours”. I am concerned that I have not seen any local protocol as to who the police should contact out of hours , and I note that EMAS do have available mental health nurses between the hours of 1am and 8am. This again appears to be a local policy and communication issue.
” 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 joined-up agency policy for s.136 detention and conveyance
Wider context from the report “2. Lack of agreed joint agency policy between EMAS and the police on s.136 MHA 1983 detentions
I issued a PFD on 17 July 2025, part way through the final inquest hearing, to raise my concern over apparent confusion with both the police and EMAS as to the applicable joint agency policy dealing with s.136 MHA 1983 detention and conveyance.
Since that PFD was issued, the evidence has developed and the position at the end of the inquest was as follows:
• The police confirmed that the document titled “Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency sections 135 and 136 Mental Health Act 1983 Procedures” has been ratified within their organisation and continues to remain the relevant joint-agency policy for s.136 detention and conveyance. This policy has been implemented for the police since its inception.
• EMAS cannot confirm whether the above policy has been ratified in its current version within the organisation. They have confirmed that an employee at EMAS signed off on the 2021 version, but that this information was never disseminated within the organisation because the finalised version of the policy remained within that employee’s email inbox. The consequence appears to be that EMAS has never implemented this policy, rather they have been working to an internal policy for Mental Health Conveyance that contains different working standards.
Acknowledging that there is no confusion for the police as to the relevant policy, and that they do consider that it has been implemented, I remain concerned. My concerns can now properly be formulated as follows:
• There is no joined up thinking between agencies on the local policy for s.136 MHA 1983 detention and conveyance . For a policy to be effective, all purported parties to that policy need to know it applies to them.
• Internal disorganisation within EMAS has culminated in a situation where, even after a period of investigation between 17 July – 25 July, they are unable to tell the Court which, if any, joint agency policy applies to them. They are unable to tell the Court whether they are still part of the relevant working group. EMAS have allowed a situation to perpetuate in which they appear, on the face of the policy documents, to be party to an agreement (which includes service level agreements for conveyance) when they simply do not know if this is correct. The upshot of this is that other agencies may be placing reliance on the conveyance terms within the policy when they are dealing with s.136 detention.
My concerns are supported by the guidance available at ss. 16.30 – 16.35 of the Mental Health Code of Practice, which highlights the importance of local policy for s.136 detention. It does not appear that there is compliance with this guidance, published by the Department of Health.
The lack of joined up thinking between agencies locally gives rise to a risk of future death for persons detained under s.136 MHA 1983.
” 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 Reliance on unrealistic self-referral for people requiring mental health and substance misuse support
Wider context from the report “6. Mental Health Services – ‘the gap’
I am concerned that there is a ‘gap’ in mental health services for those people who have a dual diagnosis of a recognised mental health condition, combined with a substance misuse diagnosis. Clinically, I understand that substance misuse can provide a barrier to effective treatment of any mental health condition. However, I have heard evidence that there is no service available to patients for management, monitoring and treatment in circumstances where they are unable to abstain from substances but require care for the residual mental health condition. In circumstances where it is clinically recognised that substance misuse can exacerbate the symptoms of many mental health conditions, this gives risk to a clear risk of future death. The evidence that I have heard is that once treatment or referral options for these patients have been exhausted, they are discharged from the Local Mental Health Team with signposting to other services e.g. substance misuse services/charities or CRISIS. These services often required self-referral, which is not realistic for many people in these circumstances . Kaine fell into this gap, and I am concerned that there is a risk of future death for other patients if this gap is not filled. Again, it seems to me that this is an issue of national concern.
” 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 align Street Triage Team capacity with current demand
Wider context from the report “5. The availability of the Street Triage Team
I heard evidence that Nottinghamshire is pioneering in its provision of a Street Triage Team, a service that has been available since 2014. This team is comprised of one police officer and one community psychiatric nurse who can travel to mental health incidents to provide assessment and advice to the response officers, particularly in relation to exercising s.136 powers.
I heard that this service is available between 8am and 1am, and that the resourcing of the service (both in terms of the shift patterns and the available cars) was determined by analysis of a data set in 2017 .
At the time that the incident arose with Kaine on 3 July 2022, no STT was available as it was out of hours.
I am concerned that there is a need to review the data to ensure that the demand for the service in 2025 is still reflected in the shift patterns . I am concerned, based on the evidence that I heard from EMAS in relation to an increase of ~60% in mental health related calls, that the demand for service may have changed since 2017 .
I note that the Mental Health Code of Practice includes the following guidance at [16.23] in relation to triage and s.136: “When deciding that detention may be necessary, the police may also benefit from seeking advice before using section 136 powers in cases where they are unsure that the circumstances are sufficiently serious for using these powers. Local protocols should set out how this advice can be provided and who the police should contact, including outside of normal business hours”. I am concerned that I have not seen any local protocol as to who the police should contact out of hours, and I note that EMAS do have available mental health nurses between the hours of 1am and 8am. This again appears to be a local policy and communication issue.
” 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 Finalise the Co-occurring Mental Health and Substance Use Delivery framework with national commitments for integrated, person-centred care.
Verbatim wording from the response “Working with subject matter experts, including people with lived experience, academics, clinicians, and service providers, the Department and NHS England are currently finalising the Co-occurring Mental Health and Substance Use Delivery framework. This framework will provide national commitments and calls to the sector on how the health system can improve delivery of integrated, person-centred care across drug and alcohol treatment and mental health services.” Source location Response from Department for Health and Social Care
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 Promote joined-up, holistic support so services collaborate to meet the full range of people’s dual-diagnosis needs.
Verbatim wording from the response “NHS England continues to promote joined-up, holistic support for people with dual diagnosis needs, ensuring services work collaboratively to meet the full range of individual needs.” Source location Response from Department for Health and Social Care
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 Issue comprehensive guidance on safe conveyance, including health-based vehicle provision and arrangements for section 136 detainees.
Verbatim wording from the response “NHS England has issued comprehensive guidance, including on the conveyance of individuals detained under section 136, which sets out that:” Source location Response from Department for Health and Social Care
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 Agreeing a joint agency policy for section 136 detentions is the responsibility of East Midlands Ambulance Service and the police.
Verbatim wording from the response “Your concern about the lack of agreed joint agency policy between East Midlands Ambulance Service and the police on section 136 detentions is a matter for those organisations.” Source location Response from Department for Health and Social Care
Open published response
25 Jul 2025 Sheldon Lawrence Jeans · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Lack of policy and guidance informing prison staff of the dangers of illicitly brewed alcohol View source Failure to secure in-possession medication against access by other prisoners View source Lack of policy and guidance governing access to and use of illicitly brewed alcohol in prisons View source Failure to ensure return of excess medication after prescription discontinuation View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sheldon Lawrence Jeans · 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 13 November 2022, Sheldon Lawrence Jeans, a serving prisoner at HMP Guys Marsh, was found collapsed and unresponsive in his cell. The inquest recorded that he died following an idiosyncratic response to alcoholic intoxication and medicinal drugs, combined with partial postural asphyxia. The report raised concerns about the lack of guidance on illicitly brewed alcohol and the governance, storage and return of medication held by prisoners.
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 policy and guidance informing prison staff of the dangers of illicitly brewed alcohol
Wider context from the report “(1) There is a lack of national policy, and local guidance at HMP Guys Marsh, to inform staff working in prisons of the dangers of illicitly brewed alcohol, also known as hooch. There is also a lack of policy and guidance to assist those working within the prisoner estate with the management and governance of the access to, and use of, illicitly brewed alcohol.
Illicitly brewed alcohol is a common substance across the prisoner estate. Evidence was given at the Inquest that in the month of September 2022, 215.5 litres of illicitly brewed alcohol were seized at HMP Guys Marsh. Evidence was given that Hooch continues to be a common problem in prisons. Illicitly brewed alcohol in prison is a substance made from items which are readily and legitimately available to prisoners.
Hooch was described as a very, very dangerous substance during the course of the evidence and as is clear from the cause of his death, was central to the death of Sheldon. Evidence was given that it has sedative effects which if taken with certain medications can increase the sedative effects.
Evidence was given that the policies in place concerning the possession and use of illicit substances within the prisoner estate at the time of Sheldon’s death, and those in place now, focus on drugs or medication, but are silent in relation to alcohol. I am concerned that this lack of guidance could lead to a future death in prison custody
” 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 secure in-possession medication against access by other prisoners
Wider context from the report “(2) Prisoners can have access to certain medication to hold in their possession which could be accessed by other prisoners and there is a lack of national policy, and local policy at HMP Guys Marsh, from a healthcare and prison perspective, around the governance of medication held in possession in the prisoner estate.
Evidence was heard that when a person is prescribed medication in prison, it can either be taken under supervision, or a prisoner can be provided with the medication to hold in their possession, in their cell.
In these cases, the prisoner is responsible for the safety of that medication. Prior to being provided with medication in their possession a risk assessment is undertaken upon the prisoner to assess the risks associated with the drug and also the risks associated with prisoner. Whilst medications defined as controlled drugs would not be given in possession, it is possible to have medication that could cause death in possession. Although Sheldon was not prescribed the medications that caused his death, evidence was given some of those medications are suitable to be prescribed to a prisoner in possession. It is not know how Sheldon accessed the medication found in his system at the time of his death, other than to say he obtained it at HMP Guys Marsh.
At HMP Guys Marsh, which may not be the case across the prisoner estate, a lockable cupboard is provided in cells for the storage of medication.
Evidence was given that at times cells will be left insecure at HMP Guys Marsh when the prison is in a state of unlock, such as when prisoners collect meals or for example when they go for showers or are out of the cells on association. Evidence was given that prisoners go into each other's cells when they are in a state of unlock. Prisoners could therefore enter another prisoner's cell. If medication is not held securely in a lockable cupboard there is a risk that prisoners who are not prescribed medication, could access medication.
Evidence was given at the Inquest that due to the chaotic life some prisoners lead, even when provided with lockable cupboards, cells at HMP Guys Marsh have been seen to contain medication that is not secure and is strewn all over the cell. The medication in Sheldon’s cell at the time of his death was found insecure in a Tupperware container.
Further, if a medication prescribed to a prisoner is discontinued, evidence was heard that the onus is upon the prisoner returning any excess medication to the healthcare department at HMP Guys Marsh which may be the position in other prisons.
The issues around securing of medication held in possession in a cell and the onus being upon prisoners to return unused medication, carries a risk of prisoners accessing unprescribed medication. At the time of Sheldon’s death he was not prescribed the medications found in his system and he had in his cell excessive amounts of medication he was prescribed and had previously been prescribed and discontinued.
I am therefore concerned the lack of guidance and policy nationally, and locally at HMP Guys Marsh, on storage of in possession medication and what to do when a medication is discontinued to ensure prisoners do not continue to possess left over medication, could lead to future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of policy and guidance governing access to and use of illicitly brewed alcohol in prisons
Wider context from the report “(1) There is a lack of national policy, and local guidance at HMP Guys Marsh, to inform staff working in prisons of the dangers of illicitly brewed alcohol, also known as hooch. There is also a lack of policy and guidance to assist those working within the prisoner estate with the management and governance of the access to, and use of, illicitly brewed alcohol.
Illicitly brewed alcohol is a common substance across the prisoner estate. Evidence was given at the Inquest that in the month of September 2022, 215.5 litres of illicitly brewed alcohol were seized at HMP Guys Marsh. Evidence was given that Hooch continues to be a common problem in prisons. Illicitly brewed alcohol in prison is a substance made from items which are readily and legitimately available to prisoners.
Hooch was described as a very, very dangerous substance during the course of the evidence and as is clear from the cause of his death, was central to the death of Sheldon. Evidence was given that it has sedative effects which if taken with certain medications can increase the sedative effects.
Evidence was given that the policies in place concerning the possession and use of illicit substances within the prisoner estate at the time of Sheldon’s death, and those in place now, focus on drugs or medication, but are silent in relation to alcohol. I am concerned that this lack of guidance could lead to a future death in prison custody
” 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 return of excess medication after prescription discontinuation
Wider context from the report “(2) Prisoners can have access to certain medication to hold in their possession which could be accessed by other prisoners and there is a lack of national policy, and local policy at HMP Guys Marsh, from a healthcare and prison perspective, around the governance of medication held in possession in the prisoner estate.
Evidence was heard that when a person is prescribed medication in prison, it can either be taken under supervision, or a prisoner can be provided with the medication to hold in their possession, in their cell.
In these cases, the prisoner is responsible for the safety of that medication. Prior to being provided with medication in their possession a risk assessment is undertaken upon the prisoner to assess the risks associated with the drug and also the risks associated with prisoner. Whilst medications defined as controlled drugs would not be given in possession, it is possible to have medication that could cause death in possession. Although Sheldon was not prescribed the medications that caused his death, evidence was given some of those medications are suitable to be prescribed to a prisoner in possession. It is not know how Sheldon accessed the medication found in his system at the time of his death, other than to say he obtained it at HMP Guys Marsh.
At HMP Guys Marsh, which may not be the case across the prisoner estate, a lockable cupboard is provided in cells for the storage of medication.
Evidence was given that at times cells will be left insecure at HMP Guys Marsh when the prison is in a state of unlock, such as when prisoners collect meals or for example when they go for showers or are out of the cells on association. Evidence was given that prisoners go into each other's cells when they are in a state of unlock. Prisoners could therefore enter another prisoner's cell. If medication is not held securely in a lockable cupboard there is a risk that prisoners who are not prescribed medication, could access medication.
Evidence was given at the Inquest that due to the chaotic life some prisoners lead, even when provided with lockable cupboards, cells at HMP Guys Marsh have been seen to contain medication that is not secure and is strewn all over the cell. The medication in Sheldon’s cell at the time of his death was found insecure in a Tupperware container.
Further, if a medication prescribed to a prisoner is discontinued, evidence was heard that the onus is upon the prisoner returning any excess medication to the healthcare department at HMP Guys Marsh which may be the position in other prisons.
The issues around securing of medication held in possession in a cell and the onus being upon prisoners to return unused medication, carries a risk of prisoners accessing unprescribed medication. At the time of Sheldon’s death he was not prescribed the medications found in his system and he had in his cell excessive amounts of medication he was prescribed and had previously been prescribed and discontinued.
I am therefore concerned the lack of guidance and policy nationally, and locally at HMP Guys Marsh, on storage of in possession medication and what to do when a medication is discontinued to ensure prisoners do not continue to possess left over medication , could lead to future deaths.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing local procedures, national standards, contractual monitoring, inspections and regional governance provide sufficient assurance for medicines safety.
Verbatim wording from the response “Procedures and governance around the management of prescription medicines will vary between different prison categories and local risks and incidents. Various processes are used to inform medicines use and safety in each prison including security and clinical incident management and review; in-cell searches and clinical therapeutic or substance misuse testing. National guidance could further complicate what is already a complex issue for both prisoners and prison staff.” Source location Response from Department for Health and Social Care
Open published response
Concerns raised 3 Failure to incorporate family and friends' concerns into onward treatment and clinical assessment View source Failure to effectively communicate with and listen to families and friends of mental health patients View source Lack of risk-assessment training for agency staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samantha Kate YOUNG · 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
Samantha Young died at home on 20 November 2023 after intentionally taking her own life by hanging. She had a history of mental health difficulties, previous suicide attempts, and worsening condition amid significant stress. The concerns included insufficient training for agency staff in risk assessments and inadequate contact and communication with patients’ families and friends.
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 incorporate family and friends' concerns into onward treatment and clinical assessment
Wider context from the report “B. Wider family and friends of the deceased perspective were not contacted.. A patient's family and friends are clearly an invaluable resource for learning more about a patient's mental health and specifically risk to life, the support available to the patient and the potential for synergistic support with the NHS Trust. This PFD is not the first time that the issue has been raised with Southern Health NHS Foundation Trust: in 2023 the Senior Coroner for Hampshire, Portsmouth and Southampton issued a PFD on similar grounds arising out of the inquest into the death of Kirsty Taylor. The Senior Coroner observed in the PFD that "I remain concerned (as it is a matter I have raised on many occasions at inquest and again as a result of the experiences of the family in this case), that communication with the families of patients with mental health difficulties is still not being effectively achieved. Nor are such families being sufficiently, effectively and meaningfully listened to or understood when they voice concerns, based on their experience of the patient outside of a treatment or assessment environment. Consequently, I am concerned that such matters are not being reflected sufficiently or frequently enough in the onward treatment of those patients or in the clinical curiosity afforded to their conditions ." Moreover, in 2021 a report commissioned by NHS England into Southern Health Foundation Trust similarly reported on shortfall in communication with families.
” 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 effectively communicate with and listen to families and friends of mental health patients
Wider context from the report “B. Wider family and friends of the deceased perspective were not contacted.. A patient's family and friends are clearly an invaluable resource for learning more about a patient's mental health and specifically risk to life, the support available to the patient and the potential for synergistic support with the NHS Trust. This PFD is not the first time that the issue has been raised with Southern Health NHS Foundation Trust: in 2023 the Senior Coroner for Hampshire, Portsmouth and Southampton issued a PFD on similar grounds arising out of the inquest into the death of Kirsty Taylor. The Senior Coroner observed in the PFD that "I remain concerned (as it is a matter I have raised on many occasions at inquest and again as a result of the experiences of the family in this case), that communication with the families of patients with mental health difficulties is still not being effectively achieved . Nor are such families being sufficiently, effectively and meaningfully listened to or understood when they voice concerns , based on their experience of the patient outside of a treatment or assessment environment. Consequently, I am concerned that such matters are not being reflected sufficiently or frequently enough in the onward treatment of those patients or in the clinical curiosity afforded to their conditions." Moreover, in 2021 a report commissioned by NHS England into Southern Health Foundation Trust similarly reported on shortfall in communication with families.
” 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 risk-assessment training for agency staff
Wider context from the report “A. Assessment of the risk that a patient poses to themselves or others is clearly a cornerstone of the work of an NHS Trust dealing with mental health. At the material time there was a lack of any training as to compilation of risk assessments . I was informed by a senior manager of Hampshire and Isle of Wight Healthcare NHS Trust that with the translation of Southern Health NHS Foundation Trust into the new Hampshire and Isle of Wight Healthcare NHS Foundation Trust that issue of training is being addressed. However it emerged at the inquest that there do not appear to be any firm plans to train agency staff . Agency staff form a significant percentage of frontline staff .
” 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 Commission and complete an independent audit of arrangements for involving and listening to families and carers.
Verbatim wording from the response “In recognition of the importance of engagement with families and carers, the Trust last year commissioned an independent audit of this area. Specifically, the purpose of the audit was to review the adequacy of the Trust’s arrangements for involving and listening to families and carers so that the Trust learns from their feedback and experiences. The findings of the audit underline the Trust’s commitment to ensuring” Source location Response from Department for Health and Social Care
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 Improve the Triangle of Care initiative to support family and carer involvement.
Verbatim wording from the response “that patients’ families feel heard, respected, and involved in the care of their loved ones. The findings also outline the programmes of work that are in place as the Trust seeks to embed a culture of compassionate, inclusive care across all of its services, which include improved collaboration with partners and other organisations; improvements to its Triangle of Care initiative; and upskilling staff coaches supporting the development of colleagues to create a culture of continuous improvement and ensure person-centred care.” Source location Response from Department for Health and Social Care
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 Consider ways to better support agency staff to develop risk-management skills.
Verbatim wording from the response “I have been informed by the Trust that the position in respect of agency staff and training is a complex one as agency nurses are employed by their agencies and typically do not have access to the in-house training programmes of the NHS Trusts they work at, for a number of logistical and financial reasons. However, given the specific focus on risk management arising from this case and more generally, the Trust is considering ways in which it can better support agency staff to develop in this area.” Source location Response from Department for Health and Social Care
Open published response
Concerns raised 2 Limited awareness of platform-lift risks and hold-to-run device retrofit feasibility View source Lack of hold-to-run controls on platform lifts View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jacqueline Mary LANGWORTHY · 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
Jacqueline Mary Langworthy, an experienced care assistant, died after becoming trapped and pinned by a stand aid in a descending platform lift; resuscitation was unsuccessful. The principal concerns were that many platform lifts lack hold-to-run controls, these controls may be relatively inexpensive to retrofit, and awareness of the risks and retrofit feasibility is limited.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Limited awareness of platform-lift risks and hold-to-run device retrofit feasibility
Wider context from the report “(1) Many platform lifts still in use in care settings and other premises do not have hold-to-run controls.
(2) Evidence was received indicating that such controls can be retrofitted at relatively low cost.
(3) There is limited awareness of both the risks posed by the absence of hold-to-run devices and the feasibility of fitting such devices to existing platform lifts.
” 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 hold-to-run controls on platform lifts
Wider context from the report “(1) Many platform lifts still in use in care settings and other premises do not have hold-to-run controls.
(2) Evidence was received indicating that such controls can be retrofitted at relatively low cost.
(3) There is limited awareness of both the risks posed by the absence of hold-to-run devices and the feasibility of fitting such devices to existing platform lifts.
” 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 matters of concern fall outside the Department of Health and Social Care’s responsibilities.
Verbatim wording from the response “The incident that led to Ms Langworthy’s death is most concerning. While the matters of concern raised by the Coroner do not fall within the responsibilities of the Department of Health and Social Care, I nonetheless share the Coroner’s concern that future deaths in similar tragic circumstances are prevented.” Source location Response from Department of Health and Social Care
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 Responsibility for platform-lift safety concerns rests with another organisation, understood to be the Health and Safety Executive.
Verbatim wording from the response “Officials within the Department of Health and Social Care have considered your report carefully and concluded that the responsibility for these concerns sits within another” Source location Response from Department for Health and Social Care
Open published response
18 Jul 2025 Patryk Gladysz · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 8 Out-of-date First Aid refresher training for healthcare staff View source Failure of prison and healthcare staff to share knowledge about people presenting with serious and enduring mental health illness View source Inconsistent understanding among prison and healthcare staff of healthcare access to NOMIS View source Ongoing challenges in prison officer checks of roll calls and ACCT observations View source Insufficient Mental Health in-reach team staffing for timely meaningful and quality mental health assessments View source Deactivation of healthcare staff NOMIS accounts due to lack of use View source Lack of prison staff knowledge of the heightened risk of foreign nationals in custody View source Staffing levels diluting key worker scheme requirements View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Patryk Gladysz · 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
Patryk Gladysz, who had schizophrenia and was detained at HMP Wandsworth, was found in his cell with a ligature around his neck on 5 January 2024 and died at St George’s Hospital. The inquest concluded that he had hung himself with a ligature, with his intentions unknown. Concerns included delays and staffing pressures affecting mental health assessments, inadequate communication between prison and healthcare staff, gaps in knowledge of his history and risks, and shortcomings in prison monitoring and training.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Out-of-date First Aid refresher training for healthcare staff
Wider context from the report “(6) First Aid refresher training is not up to date for all healthcare staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of prison and healthcare staff to share knowledge about people presenting with serious and enduring mental health illness
Wider context from the report “(4) Communication between prison and healthcare staff regarding: (a) knowledge sharing of those presenting with a serious and enduring mental health illness, such as schizophrenia ; (b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff; and (c) de-activation of NOMIS accounts for healthcare staff due to lack of use – 21 healthcare accounts were de-activated notwithstanding an increase in available terminals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistent understanding among prison and healthcare staff of healthcare access to NOMIS
Wider context from the report “(4) Communication between prison and healthcare staff regarding: (a) knowledge sharing of those presenting with a serious and enduring mental health illness, such as schizophrenia; (b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff ; and (c) de-activation of NOMIS accounts for healthcare staff due to lack of use – 21 healthcare accounts were de-activated notwithstanding an increase in available terminals.
” 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 Ongoing challenges in prison officer checks of roll calls and ACCT observations
Wider context from the report “(5) Prison officer checks of roll calls/ACCT observations - recent audit by HMP Wandsworth suggests on-going challenges .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient Mental Health in-reach team staffing for timely meaningful and quality mental health assessments
Wider context from the report “(1) Staffing within the Mental Health in-reach team impacting the timely undertaking of meaningful and quality mental health assessments .
” 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 Deactivation of healthcare staff NOMIS accounts due to lack of use
Wider context from the report “(4) Communication between prison and healthcare staff regarding: (a) knowledge sharing of those presenting with a serious and enduring mental health illness, such as schizophrenia; (b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff; and (c) de-activation of NOMIS accounts for healthcare staff due to lack of use – 21 healthcare accounts were de-activated notwithstanding an increase in available terminals .
” 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 prison staff knowledge of the heightened risk of foreign nationals in custody
Wider context from the report “(3) Knowledge of prison staff of the heightened risk of foreign nationals in custody , despite a higher proportion of foreign nationals being detained at HMP Wandsworth.
” 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 Staffing levels diluting key worker scheme requirements
Wider context from the report “(2) Staffing within HMP Wandsworth resulting in a dilution to the requirements for the key worker scheme .
” 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 Improve healthcare staff understanding of how to use the NOMIS system.
Verbatim wording from the response “You have also raised concerns around communication between prison and healthcare staff, including a lack of knowledge sharing and a lack of understanding about accessing the NOMIS system. I would agree that appropriate information sharing is essential to support the ongoing care provided to patients in prison settings. I understand that a number of fora have now been set up at HMP Wandsworth to facilitate the sharing of knowledge between prison and healthcare staff about prisoners of concern, including those with complex mental health needs, such as schizophrenia. Action has also been taken to improve understanding around the use of the NOMIS system by healthcare staff.” Source location Response from Department for Health and Social Care
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 Establish forums for prison and healthcare staff to share knowledge about prisoners of concern.
Verbatim wording from the response “You have also raised concerns around communication between prison and healthcare staff, including a lack of knowledge sharing and a lack of understanding about accessing the NOMIS system. I would agree that appropriate information sharing is essential to support the ongoing care provided to patients in prison settings. I understand that a number of fora have now been set up at HMP Wandsworth to facilitate the sharing of knowledge between prison and healthcare staff about prisoners of concern, including those with complex mental health needs, such as schizophrenia. Action has also been taken to improve understanding around the use of the NOMIS system by healthcare staff.” Source location Response from Department for Health and Social Care
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 Fill the vacant mental health in-reach team post.
Verbatim wording from the response “I understand your concerns about staffing shortages within the mental health in-reach team at HMP Wandsworth, and how that may have impacted the quality of mental health assessments. I understand from NHS England that, at the time of Mr Gladysz’s death, the team had a vacancy for one whole time equivalent staff member, and that this has now been filled. In addition, the internal patient safety investigation into Mr Gladysz’s death carried out by Oxleas NHS Foundation Trust, as the healthcare provider at HMP Wandsworth, highlighted wider staff concerns around a lack of supportive leadership at the time of the incident. I am assured by NHS England that these issues have since been addressed, with the appointment in late 2024 of a new operational manager to the prison’s mental health team.” Source location Response from Department for Health and Social Care
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 Provide role-appropriate Basic Life Support or Immediate Life Support training to all healthcare staff.
Verbatim wording from the response “Finally, with regard to your concern that first aid refresher training is not up to date for all healthcare staff, as part of the national service specification for prison healthcare, it is expected for all prison healthcare staff to be trained in basic life support, with annual refresher training included in their mandatory and statutory training plans. At HMP Wandsworth, all healthcare staff undertake Basic Life Support or Immediate Life Support training, dependent on their role.” Source location Response from Department for Health and Social Care
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 HM Prison and Probation Service or the Ministry of Justice is responsible for addressing concerns about prison staff knowledge, checks and suicide prevention observations.
Verbatim wording from the response “I would expect your concerns around poor knowledge among prison staff, prison officer checks during roll calls and suicide prevention observations to be addressed by HM Prison and Probation Service and/or the Ministry of Justice in their responses to you.” Source location Response from Department for Health and Social Care
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 mandatory training arrangements and staff completion of basic or immediate life support training address first-aid refresher concerns.
Verbatim wording from the response “Finally, with regard to your concern that first aid refresher training is not up to date for all healthcare staff, as part of the national service specification for prison healthcare, it is expected for all prison healthcare staff to be trained in basic life support, with annual refresher training included in their mandatory and statutory training plans. At HMP Wandsworth, all healthcare staff undertake Basic Life Support or Immediate Life Support training, dependent on their role.” Source location Response from Department for Health and Social Care
Open published response
10 Jul 2025 Jairus Joshua Timothy Earl · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Lack of inter-force sharing and flagging of information about shotgun licence holders and shotgun locations View source Lack of requirements for shotgun licence holders to notify police forces of additional properties and visits to other force areas View source Lack of police access to medical information about other residents during firearm and shotgun licence applications View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jairus Joshua Timothy Earl · 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
Jairus Joshua Timothy Earl, aged 15, died by suicide on 14 April 2024 after using one of his father’s shotguns at the family’s Dorset property. The concerns relate to gaps in the regulation of shotgun licences, including the lack of requirements to notify police about additional properties, inadequate information-sharing and address flagging between police forces, and limited access to medical information about other people living at a licence holder’s property.
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 inter-force sharing and flagging of information about shotgun licence holders and shotgun locations
Wider context from the report “(1) I have concerns in relation to gaps in the regulation of shotgun licences especially when a licence holder has more than one property where the guns may be used or stored. The Firearms Act 1968 (The Act) is the primary legislation that governs the possession and handling of firearms. This is supported by statutory guidance, Firearms Licensing: Statutory Guidance for Chief Officers of Police and non statutory Home Office guidance, Guide on firearms Licensing Law.
Section 2 of the Act deals with the requirement of certificate for possession of shotguns. Evidence was given at the Inquest by Acting Chief Inspector ████████ of Dorset Police who works within the Dorset Firearms and Explosive Licensing Unit and also works with the College of Policing and the national Firearms & Explosive Licencing Working Group to review and update the Home Office statutory guidance and support the national training effort in response to the Prevention of Future Deaths report from the Inquest touching upon the deaths in Keyham on 12th August 2021.
He gave evidence that the regulation for shotguns is different to the regulations for firearms which is governed by Section 1 of The Act. There seems to be a great deal of difference in the regulation of firearms and the regulation of shotguns, however both can equally cause death.
I am concerned that the lack of regulation around shotguns could lead to future deaths. For example, he explained that there is no obligation on a licence holder of a shotgun licence to notify the approving force they are moving to or visiting another property
In his written evidence to the Court, which was further expanded on orally at the Inquest, he explained:
“Under section 26B(1) of the 1968 Act, an application for the grant of a shotgun shall be made to the chief officer of police where the applicant resides, there is nothing within the firearms act to define a residence or when applicants have properties in different force areas, the non-statutory guide tells me that where an applicant has a residences in different force areas, it is for the individual to decide which force issues their certificate.
Shotgun certificates are issued by individual forces’ and will display the force crest and signature of the chief officer of the issuing force, however they are valid throughout England and Wales, and allows the holder to travel with their shotguns anywhere in the United Kingdom.
…
Shotgun certificates differ from firearm certificates in a number of ways, for firearms, possession of each and every gun must satisfy individual good reason, whereas a good reason for a shotgun is a collective term, and more relaxed, for example a request for a firearms certificate for target shooting will require that the applicant is a member of a Home Office approved club and shoots regularly, whereas a mere intention to undertake clay pigeon shooting would satisfy good reason for a shotgun certificate.
A shotgun certificate also will also authorise a person to have in their possession, purchase or acquire and unlimited number of shotguns without the need for approval in respect of individual guns, that is to say that so long as the shotguns are stored securely a person may have as many as they want.
Another nuance of the shotgun certificate is the ’72-hour rule’ that it will allow a certificate holder to borrow a shotgun for up to 72 hours without the need to have to record the shotgun on the certificate or notify the police of the transfer.
…
Section 28(2)(a) of the 1968 Act provides that a shotgun certificate is granted subject to any prescribed conditions, and no others, that is that these conditions must be applied to the certificate, but the chief officer cannot add additional conditions.
…
There is no onus on an applicant to notify another force area where they hold a certificate and have another address in that force area, this is only the case if the certificate holder changes their permanent address that this would be captured by the third condition.
There is also no obligation on a certificate holder to notify a chief officer of police when they intent to visit another force area in possession of their shotguns.
Acting Chief Inspector ████████ explained that on the Tuesday following Jairus’ death he briefed the national coordinator from the Firearms & Explosive Licencing Working Group to raise matters arising from the circumstances of Jairus’ death so there is awareness of the issues relating to second homes, however, there is no legal requirement for second homes to be declared by licence holders.
He further told the Court that in 2015, HM Inspection of Firearms Licencing recommended that forces must have a notification system on their local records to identify addresses and people where firearms are held. He explained that these systems are local rather than national and his recommendation to the Firearms & Explosive Licencing Working Group following Jairus’s death was that where an applicant declares a second home, the force where that home is located should be notified.
Dorset Police have taken action and put a system in place that when they are notified of the above, they will create a record on their system to flag the address as if that were a Dorset certificate holder, however it is not a legal requirement for forces to do this, and it is unknown if other forces nationally are doing this.
I therefore have concerns there is a lack of a system of sharing and flagging information between Police forces regarding shotgun licence holders and the location of shotguns , which could lead to future deaths.
Accordingly, emergency services may attend an address where shotguns are held without knowledge of that fact due to the lack of a marker being placed on the address . This causes a risk to all those attending unmarked addresses as they would potentially be ill prepared for what they could face which could lead to future deaths.
Additionally failing to have such markers on additional homes means that if the police are called to the address for other reasons such as a concern for welfare, they may miss the opportunity to put in place additional security measures ,or even revoke the licences , as required for the safety of the occupants at the address, and others. Evidence was heard that Dorset Police were called to Jairus’s family address in Dorset on the 28th March 2024 following a report that Jairus was missing. It was not apparent from the Police system at the time that there would be shotguns at the address. Jairus’s mental health was discussed during the report of this incident. Had the flag system been in place then, consideration could have been given to the continued possession of the shotgun in a property where Jairus could access them.
” 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 requirements for shotgun licence holders to notify police forces of additional properties and visits to other force areas
Wider context from the report “(1) I have concerns in relation to gaps in the regulation of shotgun licences especially when a licence holder has more than one property where the guns may be used or stored. The Firearms Act 1968 (The Act) is the primary legislation that governs the possession and handling of firearms. This is supported by statutory guidance, Firearms Licensing: Statutory Guidance for Chief Officers of Police and non statutory Home Office guidance, Guide on firearms Licensing Law.
Section 2 of the Act deals with the requirement of certificate for possession of shotguns. Evidence was given at the Inquest by Acting Chief Inspector ████████ of Dorset Police who works within the Dorset Firearms and Explosive Licensing Unit and also works with the College of Policing and the national Firearms & Explosive Licencing Working Group to review and update the Home Office statutory guidance and support the national training effort in response to the Prevention of Future Deaths report from the Inquest touching upon the deaths in Keyham on 12th August 2021.
He gave evidence that the regulation for shotguns is different to the regulations for firearms which is governed by Section 1 of The Act. There seems to be a great deal of difference in the regulation of firearms and the regulation of shotguns, however both can equally cause death.
I am concerned that the lack of regulation around shotguns could lead to future deaths. For example, he explained that there is no obligation on a licence holder of a shotgun licence to notify the approving force they are moving to or visiting another property
In his written evidence to the Court, which was further expanded on orally at the Inquest, he explained:
“Under section 26B(1) of the 1968 Act, an application for the grant of a shotgun shall be made to the chief officer of police where the applicant resides, there is nothing within the firearms act to define a residence or when applicants have properties in different force areas, the non-statutory guide tells me that where an applicant has a residences in different force areas, it is for the individual to decide which force issues their certificate.
Shotgun certificates are issued by individual forces’ and will display the force crest and signature of the chief officer of the issuing force, however they are valid throughout England and Wales, and allows the holder to travel with their shotguns anywhere in the United Kingdom.
…
Shotgun certificates differ from firearm certificates in a number of ways, for firearms, possession of each and every gun must satisfy individual good reason, whereas a good reason for a shotgun is a collective term, and more relaxed, for example a request for a firearms certificate for target shooting will require that the applicant is a member of a Home Office approved club and shoots regularly, whereas a mere intention to undertake clay pigeon shooting would satisfy good reason for a shotgun certificate.
A shotgun certificate also will also authorise a person to have in their possession, purchase or acquire and unlimited number of shotguns without the need for approval in respect of individual guns, that is to say that so long as the shotguns are stored securely a person may have as many as they want.
Another nuance of the shotgun certificate is the ’72-hour rule’ that it will allow a certificate holder to borrow a shotgun for up to 72 hours without the need to have to record the shotgun on the certificate or notify the police of the transfer.
…
Section 28(2)(a) of the 1968 Act provides that a shotgun certificate is granted subject to any prescribed conditions, and no others, that is that these conditions must be applied to the certificate, but the chief officer cannot add additional conditions.
…
There is no onus on an applicant to notify another force area where they hold a certificate and have another address in that force area , this is only the case if the certificate holder changes their permanent address that this would be captured by the third condition.
There is also no obligation on a certificate holder to notify a chief officer of police when they intent to visit another force area in possession of their shotguns .
Acting Chief Inspector ████████ explained that on the Tuesday following Jairus’ death he briefed the national coordinator from the Firearms & Explosive Licencing Working Group to raise matters arising from the circumstances of Jairus’ death so there is awareness of the issues relating to second homes, however, there is no legal requirement for second homes to be declared by licence holders .
He further told the Court that in 2015, HM Inspection of Firearms Licencing recommended that forces must have a notification system on their local records to identify addresses and people where firearms are held. He explained that these systems are local rather than national and his recommendation to the Firearms & Explosive Licencing Working Group following Jairus’s death was that where an applicant declares a second home, the force where that home is located should be notified.
Dorset Police have taken action and put a system in place that when they are notified of the above, they will create a record on their system to flag the address as if that were a Dorset certificate holder, however it is not a legal requirement for forces to do this, and it is unknown if other forces nationally are doing this.
I therefore have concerns there is a lack of a system of sharing and flagging information between Police forces regarding shotgun licence holders and the location of shotguns, which could lead to future deaths.
Accordingly, emergency services may attend an address where shotguns are held without knowledge of that fact due to the lack of a marker being placed on the address. This causes a risk to all those attending unmarked addresses as they would potentially be ill prepared for what they could face which could lead to future deaths.
Additionally failing to have such markers on additional homes means that if the police are called to the address for other reasons such as a concern for welfare, they may miss the opportunity to put in place additional security measures ,or even revoke the licences, as required for the safety of the occupants at the address, and others. Evidence was heard that Dorset Police were called to Jairus’s family address in Dorset on the 28th March 2024 following a report that Jairus was missing. It was not apparent from the Police system at the time that there would be shotguns at the address. Jairus’s mental health was discussed during the report of this incident. Had the flag system been in place then, consideration could have been given to the continued possession of the shotgun in a property where Jairus could access them.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of police access to medical information about other residents during firearm and shotgun licence applications
Wider context from the report “(2) Further I have a concern around the access that police forces have to medical information about other persons living at the same property as the applicant, or at their second homes, when considering firearm and shotgun licence applications. Acting Chief Inspector ████████ advised the Court that whilst Police forces can look at the medical history of the applicant and can speak to others present at the address, they have no legal right to access the medical records of others residing at the property.
The medical history of Jairus came as great surprise to the attending Police officers at the Inquest. I am concerned that the lack of access to this medical information of others residing at the address of a licence applicant, especially in relation to mental health, when considering firearms or shotgun licence applications could lead to future deaths.
” 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 Explore options and implications for broadening police access to relevant medical information about others living at firearms licence holders’ addresses.
Verbatim wording from the response “Ensuring that health and non-health data is linked effectively is vitally important to making the best decisions possible to ensure the safety and security of all. In relation to firearms licences, we must do this in a way that is proportionate and balances individuals’ rights to confidentiality with the safety of those holding firearms licences and others who could potentially access that firearm. Considering the matters you raise in connection to Mr Earl’s death, we will carefully explore the options for and implications of broadening access to relevant medical information of others residing at licence-holders' addresses.” Source location Response from Department of Health and Social Care
Open published response
10 Jul 2025 Doreen Swann · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of suitable social care placements causing delayed hospital discharges View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Doreen Swann · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Doreen Swann was a patient at Tameside General Hospital whose discharge had been delayed while she awaited a suitable social care placement. She was a high falls risk, fell while unobserved with the bed rails up, suffered a traumatic brain injury and died. The concerns included delayed discharges due to shortages of suitable social care placements, the challenges of managing high falls risk patients in an acute setting, and impacts on hospital bed availability and the Emergency Department.
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 suitable social care placements causing delayed hospital discharges
Wider context from the report “1. The inquest heard evidence that Doreen Swann was only in hospital at the point of her fall because her discharge had been delayed due to a shortage of a suitable social care placement . The evidence was that nursing/caring for high falls risk patients in an acute setting is challenging and resource intensive.
2. The evidence given to the inquest was that this delayed discharge and the ongoing risk it presents was not an isolated incident at TGH -as an example the evidence given was that there were regularly 30 plus patients with a delayed discharge over 3 weeks due to a lack of social care beds .The evidence indicated that this challenge was not unique to Tameside.
3. The evidence indicated that managing a falls risk and the consequential risk to life is better managed outside an acute setting once the clinical need for a hospital stay has passed .
4. Delayed discharges such as Doreen Swann’s reduces the availability of beds for other patients and creates a knock-on impact across the hospital particularly in relation to the Emergency Department .
” 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 Provide £9 billion through the Better Care Fund to support integrated health and social care and shared discharge-planning accountability.
Verbatim wording from the response “The Better Care Fund (BCF) is a key part of our plan to address these delays, particularly when they are caused by a shortage of suitable social care, by supporting Integrated Care Boards and local authorities to deliver joined-up health and social care. This year, the BCF will provide £9 billion to help ensure patients receive the right care in the right place, with shared accountability for discharge planning.” Source location Response from Department of Health and Social Care
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 Provide over £4 billion in additional adult social care funding by 2028–29 to help local authorities improve services and meet statutory duties.
Verbatim wording from the response “Additionally, the Spending Review includes over £4 billion additional funding for adult social care by 2028-29, compared to 2025-26, helping local authorities improve services and meet their duties under the Care Act 2014.” Source location Response from Department of Health and Social Care
Open published response
9 Jul 2025 Andrew Nathan Paul Kenward · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 6 Lack of restrictions on import of reportable substances View source Failure to consider whether sale purity and quantities are necessary for legitimate use View source Lack of domestic restrictions on purchase of reportable substances View source Lack of regulation and monitoring of substance use beyond the Poisons Act View source Lack of central monitoring of sodium nitrite poisoning incidents View source Sale of reportable substances at lethal purity and quantities View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew Nathan Paul Kenward · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew Nathan Paul Kenward was found deceased in his car on 24 October 2022 after an overdose of a poisonous substance. He had previously expressed an intention to end his life, and the inquest recorded a conclusion of suicide. The concerns included the availability, purity and quantity of certain reportable substances, limited monitoring and restrictions, and the absence of apparent consideration of measures to reduce the risk to life.
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 restrictions on import of reportable substances
Wider context from the report “A lethal dose of ████████ can be as small as 1g. Mr Kenward was able to procure a total of 1kg of ████████ at 99.999% purity.
Coroners including myself have previously raised in Prevention of Future Death reports that there is no central monitoring system which is able to record incidents of sodium nitrite poisoning, although the use of sodium nitrite for self-harm is increasing.
████████ and ████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. Whilst the source of this particular ████████ is not currently known, there are no restrictions on the import of ████████ or ████████ from abroad .
Whilst these substances have legitimate uses, including meat preservation, there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions ;
- ████████ is sold at levels of purity (99%) and in quantities which represent significant risk to life (up to 1000 fatal doses for 1kg sale), whether by self-harm or terrorist use;
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in meat preservation;
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this.
Consideration should be given as to whether any steps can be taken to address the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to consider whether sale purity and quantities are necessary for legitimate use
Wider context from the report “A lethal dose of ████████ can be as small as 1g. Mr Kenward was able to procure a total of 1kg of ████████ at 99.999% purity.
Coroners including myself have previously raised in Prevention of Future Death reports that there is no central monitoring system which is able to record incidents of sodium nitrite poisoning, although the use of sodium nitrite for self-harm is increasing.
████████ and ████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. Whilst the source of this particular ████████ is not currently known, there are no restrictions on the import of ████████ or ████████ from abroad.
Whilst these substances have legitimate uses, including meat preservation, there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold , against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions;
- ████████ is sold at levels of purity (99%) and in quantities which represent significant risk to life (up to 1000 fatal doses for 1kg sale), whether by self-harm or terrorist use;
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use , for example in meat preservation;
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this.
Consideration should be given as to whether any steps can be taken to address the above concerns.
” 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 domestic restrictions on purchase of reportable substances
Wider context from the report “A lethal dose of ████████ can be as small as 1g. Mr Kenward was able to procure a total of 1kg of ████████ at 99.999% purity.
Coroners including myself have previously raised in Prevention of Future Death reports that there is no central monitoring system which is able to record incidents of sodium nitrite poisoning, although the use of sodium nitrite for self-harm is increasing.
████████ and ████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious . Whilst the source of this particular ████████ is not currently known, there are no restrictions on the import of ████████ or ████████ from abroad.
Whilst these substances have legitimate uses, including meat preservation, there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions ;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions;
- ████████ is sold at levels of purity (99%) and in quantities which represent significant risk to life (up to 1000 fatal doses for 1kg sale), whether by self-harm or terrorist use;
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in meat preservation;
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this.
Consideration should be given as to whether any steps can be taken to address the above concerns.
” 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 regulation and monitoring of substance use beyond the Poisons Act
Wider context from the report “A lethal dose of ████████ can be as small as 1g. Mr Kenward was able to procure a total of 1kg of ████████ at 99.999% purity.
Coroners including myself have previously raised in Prevention of Future Death reports that there is no central monitoring system which is able to record incidents of sodium nitrite poisoning, although the use of sodium nitrite for self-harm is increasing.
████████ and ████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. Whilst the source of this particular ████████ is not currently known, there are no restrictions on the import of ████████ or ████████ from abroad.
Whilst these substances have legitimate uses, including meat preservation, there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions;
- ████████ is sold at levels of purity (99%) and in quantities which represent significant risk to life (up to 1000 fatal doses for 1kg sale), whether by self-harm or terrorist use;
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in meat preservation;
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972 , and it is not clear which Government department would be responsible for this .
Consideration should be given as to whether any steps can be taken to address the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of central monitoring of sodium nitrite poisoning incidents
Wider context from the report “A lethal dose of ████████ can be as small as 1g. Mr Kenward was able to procure a total of 1kg of ████████ at 99.999% purity.
Coroners including myself have previously raised in Prevention of Future Death reports that there is no central monitoring system which is able to record incidents of sodium nitrite poisoning , although the use of sodium nitrite for self-harm is increasing.
████████ and ████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. Whilst the source of this particular ████████ is not currently known, there are no restrictions on the import of ████████ or ████████ from abroad.
Whilst these substances have legitimate uses, including meat preservation, there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions;
- ████████ is sold at levels of purity (99%) and in quantities which represent significant risk to life (up to 1000 fatal doses for 1kg sale), whether by self-harm or terrorist use;
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in meat preservation;
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this.
Consideration should be given as to whether any steps can be taken to address the above concerns.
” 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 Sale of reportable substances at lethal purity and quantities
Wider context from the report “A lethal dose of ████████ can be as small as 1g . Mr Kenward was able to procure a total of 1kg of ████████ at 99.999% purity.
Coroners including myself have previously raised in Prevention of Future Death reports that there is no central monitoring system which is able to record incidents of sodium nitrite poisoning, although the use of sodium nitrite for self-harm is increasing.
████████ and ████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. Whilst the source of this particular ████████ is not currently known, there are no restrictions on the import of ████████ or ████████ from abroad.
Whilst these substances have legitimate uses, including meat preservation, there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions;
- ████████ is sold at levels of purity (99%) and in quantities which represent significant risk to life (up to 1000 fatal doses for 1kg sale) , whether by self-harm or terrorist use;
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in meat preservation;
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this.
Consideration should be given as to whether any steps can be taken to address the above concerns.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for concerns about access to large amounts of sodium nitrite sits with another organisation.
Verbatim wording from the response “The report raises concerns over the fact that Mr Kenward was able to buy large amounts of sodium nitrite. Officials within the Department of Health and Social Care have considered these concerns and concluded that the responsibility for these concerns sits within another organisation. I understand that this report was also made to the Home Office, and I hope that their response will be helpful.” Source location Response from Department for Health and Social Care
Open published response
7 Jul 2025 Sarah Jayne Lewis · Prevention of Future Deaths report Avon
View report summary
Concerns raised 6 Insufficient research into ME View source Incomplete use of hospital passports for people with ME View source Inconsistent or unavailable provision of ME services View source Failure of commissioning bodies to fully consider or implement NICE ME guidance View source Failure to recognise ME as a real condition View source Lack of professional understanding and training about ME View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sarah Jayne Lewis · 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
Sarah Jayne Lewis, who had severe ME/CFS and was largely bedbound, was found deceased at home on 9 August 2024 after taking an overdose with the intention of ending her life. The inquest concluded suicide, with acute toxicity recorded as the cause of death. Concerns included inconsistent national provision of ME services, limited research and treatment options, insufficient professional understanding and training, and unclear implementation of updated NICE guidance.
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 research into ME
Wider context from the report “(2) Historically, there has been little research into ME . As a result of this, nobody knows what causes it, and there is therefore no cure. Whilst I note there has been a small investment recently in research, I was told that this is not enough , and that a perception remains about ME not being real. The resultant effect is that some ME sufferers have no hope that their symptoms will ever improve.
” 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 Incomplete use of hospital passports for people with ME
Wider context from the report “(3) Other professionals do not understand ME, what it is or the symptoms it causes. This can be a barrier to those with ME receiving support, or accessing care/treatment they need. A hospital passport is now being utilised at North Bristol, which assists sufferers. However, it is not clear that this is being used in all areas , and there remains a lack of understanding about ME. Education and training about this has not been prioritised.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistent or unavailable provision of ME services
Wider context from the report “(1) Despite ME having received some more recent attention, the provision of ME services around the country remains inconsistent . I understand that there are still areas where there is no provision . The evidence revealed that a very important first stage for ME suffers is that they receive a diagnosis and validation for their severe symptoms. Without provision of a service, there remains a risk that this will not occur. I was told that there is still a belief by some that ME is not real and this has a profoundly negative effect on sufferers and their ability to seek support.
” 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 commissioning bodies to fully consider or implement NICE ME guidance
Wider context from the report “(4) NICE issued update guidance relatively recently but it is not clear whether this has been fully considered or implemented by commissioning bodies around 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 recognise ME as a real condition
Wider context from the report “(1) Despite ME having received some more recent attention, the provision of ME services around the country remains inconsistent. I understand that there are still areas where there is no provision. The evidence revealed that a very important first stage for ME suffers is that they receive a diagnosis and validation for their severe symptoms. Without provision of a service, there remains a risk that this will not occur. I was told that there is still a belief by some that ME is not real and this has a profoundly negative effect on sufferers and their ability to seek support.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of professional understanding and training about ME
Wider context from the report “(3) Other professionals do not understand ME, what it is or the symptoms it causes . This can be a barrier to those with ME receiving support, or accessing care/treatment they need. A hospital passport is now being utilised at North Bristol, which assists sufferers. However, it is not clear that this is being used in all areas, and there remains a lack of understanding about ME . Education and training about this has not been prioritised .
” 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 Explore next steps with the Medical Research Council to increase ME/CFS research volume and application quality.
Verbatim wording from the response “Together with the MRC, we are actively exploring next steps for research in ME/CFS. In the ME/CFS Final Delivery Plan, we have outlined the research actions and additional support that we will offer to the research community to increase the volume and quality of applications. This includes a new funding opportunity for a development award focussed on evaluating repurposed pharmaceutical interventions for post-acute infection syndromes and associated conditions, including ME/CFS. This funding opportunity is a key component of our response to the need for further research-based evidence related to the diagnosis, management and treatment of post-acute infection conditions, including ME/CFS. We are” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore whether to prescribe a specialised service for people with very severe ME/CFS.
Verbatim wording from the response “NHS England remains committed to collaborating with DHSC on the implementation of the ME/CFS Final Delivery Plan, with a view to supporting integrated care boards to ensure equitable access and evidence-based care, including implementation of the 2021 NICE guidance on ME/CFS. This partnership will support the integration of best practices and insights to enhance service quality and consistency across the system. More specifically, within the ME/CFS Final Delivery Plan, NHS England will co-design resources for systems to improve services for mild and moderate ME/CFS. Additionally, DHSC, with NHS England, will explore whether a specialised service should be prescribed by the Secretary of State for Health for very severe ME/CFS.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the ME/CFS Final Delivery Plan to improve research, education, attitudes and patient outcomes.
Verbatim wording from the response “The Department of Health and Social Care (DHSC) published the ME/CFS Final Delivery Plan on 22 July, which can be found here: https://www.gov.uk/government/publications/mecfs-the-final-delivery-plan. The plan focuses on boosting research, improving attitudes and education, and bettering the lives of people with this debilitating disease. We have worked closely with ME/CFS patients, carers, clinicians, charities, research funders and researchers throughout the development of the interim and final delivery plans. This engagement has enabled us to develop new and more ambitious actions that deliver meaningful change for the ME/CFS community.” Source location Response from Department of Health and Social Care
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 Provide a new funding opportunity to evaluate repurposed pharmaceutical interventions for post-acute infection syndromes, including ME/CFS.
Verbatim wording from the response “Together with the MRC, we are actively exploring next steps for research in ME/CFS. In the ME/CFS Final Delivery Plan, we have outlined the research actions and additional support that we will offer to the research community to increase the volume and quality of applications. This includes a new funding opportunity for a development award focussed on evaluating repurposed pharmaceutical interventions for post-acute infection syndromes and associated conditions, including ME/CFS. This funding opportunity is a key component of our response to the need for further research-based evidence related to the diagnosis, management and treatment of post-acute infection conditions, including ME/CFS. We are” Source location Response from Department of Health and Social Care
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 Host an NIHR and Medical Research Council showcase event for post-acute infection conditions research, including ME/CFS.
Verbatim wording from the response “also planning an NIHR and MRC hosted showcase event for post-acute infection conditions (including ME/CFS and long COVID) research later this year to stimulate further research in this field.” Source location Response from Department of Health and Social Care
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 Continue promoting ME/CFS e-learning through professional, sector and representative networks and targeted communications.
Verbatim wording from the response “DHSC will continue to reach out to its networks, including the Royal College of Nursing, to promote the e-learning, and will issue targeted communications regarding the e-learning via wider sector networks, such as the Health and Wellbeing Boards, adult social care provider networks, and representative bodies and charities.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with NHS England to develop e-learning for healthcare and other professionals on ME/CFS.
Verbatim wording from the response “In relation to the issue of some people still perceiving ME/CFS as not being real and healthcare and other professionals misunderstanding ME/CFS, the Department has been working closely with NHS England to develop an e-learning course on ME/CFS for healthcare and other professionals, with the aim of supporting staff to be able to provide better care and improve patient outcomes. NHS England’s e-learning package comprises three sessions.” Source location Response from Department of Health and Social Care
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 ME/CFS research funding depends on the volume and quality of applications, peer review, scientific quality, importance and value for money.
Verbatim wording from the response “DHSC funds research on health and social care through the National Institute for Health and Care Research (NIHR). The NIHR and Medical Research Council (MRC, part of UK Research and Innovation) remain committed to funding high-quality research to understand the causes, consequences, and treatment of ME/CFS.” Source location Response from Department of Health and Social Care
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 Research funding decisions for ME/CFS are made through NIHR and MRC funding processes rather than directly by the Department.
Verbatim wording from the response “DHSC funds research on health and social care through the National Institute for Health and Care Research (NIHR). The NIHR and Medical Research Council (MRC, part of UK Research and Innovation) remain committed to funding high-quality research to understand the causes, consequences, and treatment of ME/CFS.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NICE guidelines are not mandatory, although commissioners are expected to take them fully into account and work towards implementation.
Verbatim wording from the response “I understand that the National Institute for Health and Care Excellence (NICE) will be replying separately. I would like to reassure you that whilst NICE guidelines are not mandatory, the Government does expect healthcare commissioners to take the guidelines fully into account in designing services to meet the needs of their local population and to work towards their implementation over time. NICE has also recently published a Clinical Knowledge Summary on ME/CFS, available at the following link: Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) | Health topics A to Z | CKS | NICE.” Source location Response from Department of Health and Social Care
Open published response
4 Jul 2025 Daniel Norman Hatchett · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Failure of chronic disease review templates to include mental health review View source Insufficient GP appointment time for holistic review of patients with chronic disease View source Undisclosed mental health concerns among middle aged men in general practice View source Mental health decline among patients with chronic disease View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Daniel Norman Hatchett · 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 Norman Hatchett had declining physical and mental health, including stress alongside chronic health conditions. In the early hours of 9 November 2024, he was found hanging at home and pronounced dead at the scene; the circumstances were deemed non-suspicious. The report identified missed opportunities for mental health follow-up and therapy, and concerns about chronic disease reviews not adequately addressing patients’ mental health, particularly where men may not disclose concerns without being asked directly.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of chronic disease review templates to include mental health review
Wider context from the report “3. Templates for GPs, to assist them in reviewing patients with chronic disease, do not include a section for review of mental health. It was considered that such a requirement could assist in identifying patients whose mental health has been adversely affected by declining physical health. This would allow the opportunity for necessary mental health support to be offered to these 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 Insufficient GP appointment time for holistic review of patients with chronic disease
Wider context from the report “2. GP appointment timings are often insufficient for the necessary holistic review of this cohort of 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 Undisclosed mental health concerns among middle aged men in general practice
Wider context from the report “4. The inquest heard that it is well known that middle aged men infrequently open up to their GP to express concerns about their mental health. An express question on a chronic disease review could help to elicit concerns that would otherwise remain undiscovered.
” 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 Mental health decline among patients with chronic disease
Wider context from the report “1. Patients with chronic disease often present with concomitant mental health decline.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Send Waltham Forest Talking Therapies website and telephone details to patients with chronic diseases or stress.
Verbatim wording from the response “As a practice, we will now send out the Waltham Forest Talking therapy (IAPT) website details and phone number to all of our patients with chronic diseases, and with stress, so they are sign-posted to seek help.” Source location Response from Department for Health and Social Care
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 Launch a call for evidence to inform England’s first men’s health strategy.
Verbatim wording from the response “I know how important it is that we understand the challenges that men face in seeking help so we can ensure that the care they receive meets their needs. We launched a 12 week call for evidence in April 2025, asking men of all ages to come forward and lend into England’s first ever men’s health strategy. This was the crucial first step in understanding what works and what doesn’t and how we can design services men will actually use. The call for evidence closed on 17 July 2025 and we are now analysing responses to inform the development of our strategy.” Source location Response from Department for Health and Social Care
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 Ask more questions about mental health and seek patients needing additional help during physical-health care.
Verbatim wording from the response “We have learnt that we cannot make assumptions that someone is mentally well by their appearance, and we will ask more questions about mental health and seek out those who need more help when they have physical health problems.” Source location Response from Department for Health and Social Care
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 Analyse responses to the men’s health strategy call for evidence to inform strategy development.
Verbatim wording from the response “I know how important it is that we understand the challenges that men face in seeking help so we can ensure that the care they receive meets their needs. We launched a 12 week call for evidence in April 2025, asking men of all ages to come forward and lend into England’s first ever men’s health strategy. This was the crucial first step in understanding what works and what doesn’t and how we can design services men will actually use. The call for evidence closed on 17 July 2025 and we are now analysing responses to inform the development of our strategy.” Source location Response from Department for Health and Social Care
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 General practices are responsible for operating arrangements, including individual appointment duration and addressing patients’ physical and mental health needs.
Verbatim wording from the response “As clinical professionals, we expect that GPs conduct their appointments with sufficient time to address their patients’ needs and to appropriately assess any health concerns. General Practices are independent businesses and are therefore responsible for the way they operate, including the duration of individual appointments. This framework allows GPs to appropriately identify both physical and mental health issues, ensure thorough assessment, and provide timely interventions or referrals where necessary.” Source location Response from Department for Health and Social Care
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 Appointment time constraints mean clinicians often rely on patients and families to disclose mental health problems rather than proactively identifying them.
Verbatim wording from the response “As clinicians we will aim to do better and ask open-ended questions about alcohol use, stress and low mood as much as possible but we realise the time constraints on us means we often rely on the patient & families to alert us about these problems.” Source location Response from Department for Health and Social Care
Open published response
2 Jul 2025 Neil John Clarke · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Inaccurate handover communications for patients returning from HDU to the main ward View source Failure to consider more conservative measures for elderly patients undergoing surgical procedures View source Inadequate documentation and guidance on different treatment choices View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Neil John Clarke · 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
Neil John Clarke, aged 81, died at Stepping Hill Hospital on 26 February 2024 after vomiting, aspiration and a cardiac arrest following a right hemicolectomy. The report raises concerns about the safety and wellbeing considerations for surgical procedures involving elderly patients, documentation and guidance about treatment choices, and the accuracy of handover communications when patients return to the main ward from HDU.
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 Inaccurate handover communications for patients returning from HDU to the main ward
Wider context from the report “The considerations given to the appropriateness, from a safety and well-being perspective, of surgical procedures involving elderly patients who may benefit from more conservative measures and the associated documentation and guidance advising patients of different treatment choices.
My second concern arising from this interest was the accuracy of hand over communications between clinical staff in respect of patients returning to the main ward from HDU .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to consider more conservative measures for elderly patients undergoing surgical procedures
Wider context from the report “The considerations given to the appropriateness, from a safety and well-being perspective, of surgical procedures involving elderly patients who may benefit from more conservative measures and the associated documentation and guidance advising patients of different treatment choices.
My second concern arising from this interest was the accuracy of hand over communications between clinical staff in respect of patients returning to the main ward from HDU.
” 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 documentation and guidance on different treatment choices
Wider context from the report “The considerations given to the appropriateness, from a safety and well-being perspective, of surgical procedures involving elderly patients who may benefit from more conservative measures and the associated documentation and guidance advising patients of different treatment choices .
My second concern arising from this interest was the accuracy of hand over communications between clinical staff in respect of patients returning to the main ward from HDU.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing national perioperative guidance and mandatory shared-decision-making training are considered sufficient to address surgical safety concerns for elderly patients.
Verbatim wording from the response “You will be aware; from the response you received from NHS England that there is clear national guidance on perioperative care for both adults and specifically older people from the National Institute for Health and Care Excellence (NICE) and the British Geriatrics Society (BGS). NHS England has also undertaken considerable work to develop guidance on Early screening, triaging, risk assessment and health optimisation in perioperative pathways. This includes information on risk assessment and shared decision making. In response to your first concern, I am assured that Stockport NHS Foundation Trust have taken steps to improve information and training relating to shared decision making and consent. In July this year the Trust rolled out a mandatory training programme that all clinical staff delivering patient care are required to be enrolled on.” Source location Response from Department for Health and Social Care
Open published response
30 Jun 2025 Thomas Raymond Mallinson · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 6 Lack of clear responsibility for care of patients during illness View source Failure to notify NWAS when referred emergency calls remain unresolved View source Overcomplexity of the care system obscuring urgent care needs View source Insufficient overnight capacity to triage waiting calls View source Failure to alert call handlers to recent same-condition contacts View source Failure to alert control when transferred emergency cases remain unresolved View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Thomas Raymond Mallinson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas Raymond Mallinson became unwell with vomiting and diarrhoea and, after repeated contacts with health services over four days, was admitted to hospital gravely ill. He developed cardiogenic shock and acute kidney failure and died on 23 November 2024. The report raised concerns about delays and gaps in responsibility and communication across general practice, out-of-hours care, and ambulance services, and described the delay as amounting to neglect.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clear responsibility for care of patients during illness
Wider context from the report “(1) To SSP Health, owners and operators of Carlisle Central Practice, 65 Warwick Road, Carlisle.
I wish to thank ████████ for his attendance and and assistance at the hearing. It was acknowledged that on 18th the advice "to call back tomorrow" should never have been given and that the telephone appointment the following day really ought to have been a face to face assessment either in surgery or at Thomas's home. I am concerned that no body or organization has taken responsibility for Thomas, an elderly man with significant co-morbidities, during his illness. Should this responsibility ultimately rest with a patients general practitioner, if not where does it rest?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to notify NWAS when referred emergency calls remain unresolved
Wider context from the report “(2) To Cumbria Health (CH).
Thomas's case was sent electronically to the service, marked for 2 hour attention. I appreciate why this did not take place as it was impossible for clinicians on night duty to triage a large number of calls waiting while actually visiting and treating their caseload. I note a new "OPEL" system has since been instituted to try to escalate and get extra help as the number of calls waiting increases, but where will these extra resources come from overnight? I am also concerned that the referral from NWAS came as a result of a 999 emergency phone call but there seemed to be no way of telling NWAS that the call had not been dealt with and (presumably) passing responsibility back to them . As referred to above -where does responsibility lie?
” 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 Overcomplexity of the care system obscuring urgent care needs
Wider context from the report “(4) To ████████, Secretary of State for Health.
In my summing up after hearing the evidence in this case I explained the legal concept of neglect as a failure to provide basic care and (in this case) medical attention for someone in a dependent condition who can not provide it for himself, and I remarked that I felt Thomas "had fallen through an overcomplex system and was indeed neglected". I am aware that you are hoping to develop a 10 year plan for the NHS and therefore feel it my duty to highlight this case to you as an example of how overcomplexity has lost sight of a man's urgent care needs .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient overnight capacity to triage waiting calls
Wider context from the report “(2) To Cumbria Health (CH).
Thomas's case was sent electronically to the service, marked for 2 hour attention. I appreciate why this did not take place as it was impossible for clinicians on night duty to triage a large number of calls waiting while actually visiting and treating their caseload . I note a new "OPEL" system has since been instituted to try to escalate and get extra help as the number of calls waiting increases, but where will these extra resources come from overnight? I am also concerned that the referral from NWAS came as a result of a 999 emergency phone call but there seemed to be no way of telling NWAS that the call had not been dealt with and (presumably) passing responsibility back to them. As referred to above -where does responsibility lie?
” 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 alert call handlers to recent same-condition contacts
Wider context from the report “(3) To Northwest Ambulance Service (NWAS) as providers of both 111 and 999 responses in Cumbria.
There were multiple calls to 111 and 999 in this case. I was told that there was no alert to a call handler to indicate recent contacts for the same patient with the same condition which might highlight a need for more decisive action. I am also concerned that (as above) there is no system that alerts your control to the fact that a 999 (emergency) case you have passed to another agency has not fact been dealt with. A further concern refers specifically to the 111 service. At inquest it was questioned whether for out of hours GP services Cumbria had been better served when calls went to a local control room in Carlisle.
” 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 alert control when transferred emergency cases remain unresolved
Wider context from the report “(3) To Northwest Ambulance Service (NWAS) as providers of both 111 and 999 responses in Cumbria.
There were multiple calls to 111 and 999 in this case. I was told that there was no alert to a call handler to indicate recent contacts for the same patient with the same condition which might highlight a need for more decisive action. I am also concerned that (as above) there is no system that alerts your control to the fact that a 999 (emergency) case you have passed to another agency has not fact been dealt with . A further concern refers specifically to the 111 service. At inquest it was questioned whether for out of hours GP services Cumbria had been better served when calls went to a local control room in Carlisle.
” 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 Implement recommendations from the NHS 111 review to make the service quicker and simpler to navigate.
Verbatim wording from the response “• Commit to implement the recommendations from the NHS 111 review to make the service quicker and simpler to navigate.” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce outcomes-based funding, integrated digital records and personalised care plans.
Verbatim wording from the response “The plan also commits to a whole-system reform by creating a new NHS operating model, outcomes-based funding, integrated digital records, and personalised care plans, ensuring services work together rather than in isolation. It aims to reduce overcomplexity through system-wide working and joined-up pathways. With respect to clinical neglect, the plan outlines a commitment to a new era of transparency, improved quality of care for all, and stronger inclusion of patient and staff voices. This effort aims to address and prevent unnecessary suffering caused by healthcare failures and broader issues within the NHS.” Source location Response from Department for Health and Social Care
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 Create a new NHS operating model to support whole-system, outcomes-based reform.
Verbatim wording from the response “The plan also commits to a whole-system reform by creating a new NHS operating model, outcomes-based funding, integrated digital records, and personalised care plans, ensuring services work together rather than in isolation. It aims to reduce overcomplexity through system-wide working and joined-up pathways. With respect to clinical neglect, the plan outlines a commitment to a new era of transparency, improved quality of care for all, and stronger inclusion of patient and staff voices. This effort aims to address and prevent unnecessary suffering caused by healthcare failures and broader issues within the NHS.” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the clinical review findings by expanding overnight support for 999 call handlers and clinicians and providing urgent in-home care with next-day follow-up.
Verbatim wording from the response “• Undertake and implement the findings of an evidence-based clinical review of categorisation, with the aim of improving the clinical triage of 999 calls, by expanding overnight support for 999 call handlers and clinicians to provide urgent in-home care for clinically assessed patients with follow-up services available the next day.” Source location Response from Department for Health and Social Care
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 Responses to GP handling, GP–999 communication, and NHS 111–999 information-transfer concerns are assigned to SSP Health, Cumbria Health, and North West Ambulance Service.
Verbatim wording from the response “Your report raises concerns of initial GP handling of the incident, high demand and communication issues between GP and 999 services, and information transfers between NHS111 and 999 in the North West. I understand that the SSP Health, Cumbria Health, and North West Ambulance Service should be responding to these respective concerns in due course. You also notified this case to the Secretary State in the context of an ’overcomplex system’ and the development of the 10-Year Health Plan. This response provides you an update in relation to this Plan and our work to improve urgent and emergency care (UEC) services.” Source location Response from Department for Health and Social Care
Open published response
27 Jun 2025 Susan Elizabeth CLISSOLD · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1 Failure to maintain sufficient community nursing capacity for required patient appointments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Susan Elizabeth CLISSOLD · 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
Susan Elizabeth CLISSOLD had multiple sclerosis, was registered blind, and received care for a pressure sore and a burn. She was admitted to hospital with symptoms of infection, her condition later deteriorated, and she died on 9 June 2024. The report raised concerns that district nurses sometimes could not attend required appointments because of insufficient staffing, in the context of increasingly complex cases and growing demand for community nursing support.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain sufficient community nursing capacity for required patient appointments
Wider context from the report “1. District nurses were required to attend to Mrs Clissold on a weekly basis. On several occasions they did not attend because they did not have sufficient members of the team available.
2. Evidence was heard that individual cases are becoming more complex involving greater input from the community nursing team and there are an increasing number of patients requiring support.
3. Norfolk Community Health and Care NHS Trust has taken steps to try to ensure there are sufficient staff to attend to patients in the community as required, such as by relocating staff on a temporary basis and prioritising patients.
4. However, evidence was heard they are not able to attend to every appointment as required
” 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 Publish a 10 Year Workforce Plan to support a sufficient and skilled NHS workforce.
Verbatim wording from the response “While the direct responsibility for the quality and number of district nurses sits with local Integrated Care Board and NHS trusts, I would like to assure you that the government recognises the constraints in which the NHS has operated in recent years. That is why this Government will publish a 10 Year Workforce Plan in spring to ensure we have a sufficient and skilled NHS workforce able to provide the right care, at the right time, in the right place.” Source location Response from Department for Health and Social Care
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 Responsibility for the number and quality of district nurses rests with local Integrated Care Boards and NHS trusts.
Verbatim wording from the response “Officials within the Department of Health and Social Care have considered these concerns and concluded that the responsibility for the number and quality of district nurses sits with local Integrated Care Boards and NHS trusts. You may find it useful to redirect the Regulation 28 Report to those bodies to get a full and comprehensive response on the matters you have raised.” Source location Response from Department for Health and Social Care
Open published response
27 Jun 2025 Brenda Fisher · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Risk of death from patients remaining for lengthy periods in areas not designed or intended for observations and care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brenda Fisher · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Brenda Fisher died at Stepping Hill Hospital on 16 January 2025 following complications from wounds sustained in a minor accident at home, with her death contributed to by rhabdomyolysis. The court heard that during her final hospital attendance she remained in the Emergency Department’s Rapid Assessment and Triage Corridor for at least 23 hours before a bed was found. The concern was the residual and inherent risk of death when patients remain for lengthy periods in areas not designed for observations and care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Risk of death from patients remaining for lengthy periods in areas not designed or intended for observations and care
Wider context from the report “The court heard evidence that on her final attendance to hospital, Mrs Fisher was cared for in the Emergency Department’s ‘Rapid Assessment and Triage’ Corridor for at least 23 hours before a bed was found for her.
Whilst the Trust has undertaken a number of steps locally to mitigate the risks associated with this practice, I am concerned that there remains a residual and inherent risk of death arising from patients remaining for lengthy periods in areas not designed or intended for undertaking observations and providing care .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Separate urgent from emergency care so patients are treated in the most appropriate setting.
Verbatim wording from the response “In June 2025, we published the Urgent and Emergency Care Plan for 2025/26. The Plan sets out the steps we are taking to tackle corridor care and reduce 12-hour waits in A&E Department’s, including a commitment to eliminate corridor care by improving patient flow. The plan also provides almost £450 million of capital investment including for Same Day Emergency Care and Urgent Treatment Centres. We will provide clear pathways and the right waiting environment when people do need to come to a hospital site with an urgent need. We will take a significant step to separate urgent from emergency care, so that people are treated in the most appropriate setting.” Source location Response from Department of Health and Social Care
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 Provide clear pathways and appropriate waiting environments for people attending hospital with urgent needs.
Verbatim wording from the response “In June 2025, we published the Urgent and Emergency Care Plan for 2025/26. The Plan sets out the steps we are taking to tackle corridor care and reduce 12-hour waits in A&E Department’s, including a commitment to eliminate corridor care by improving patient flow. The plan also provides almost £450 million of capital investment including for Same Day Emergency Care and Urgent Treatment Centres. We will provide clear pathways and the right waiting environment when people do need to come to a hospital site with an urgent need. We will take a significant step to separate urgent from emergency care, so that people are treated in the most appropriate setting.” Source location Response from Department of Health and Social Care
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 Eliminate corridor care by improving patient flow.
Verbatim wording from the response “In June 2025, we published the Urgent and Emergency Care Plan for 2025/26. The Plan sets out the steps we are taking to tackle corridor care and reduce 12-hour waits in A&E Department’s, including a commitment to eliminate corridor care by improving patient flow. The plan also provides almost £450 million of capital investment including for Same Day Emergency Care and Urgent Treatment Centres. We will provide clear pathways and the right waiting environment when people do need to come to a hospital site with an urgent need. We will take a significant step to separate urgent from emergency care, so that people are treated in the most appropriate setting.” Source location Response from Department of Health and Social Care
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 Expand access to urgent care services at home and in the community through the Neighbourhood Health model.
Verbatim wording from the response “In July 2025, we published the Ten Year Health Plan to create a new model of care, fit for the future. A key focus of our approach will be to expand access to urgent care services at home and in the community as part of our new Neighbourhood Health model. This will improve the experience and care that people receive, rather than having to go to hospital unnecessarily. This will reduce demand in ED’s, meaning that they are liberated to focus on providing the best, most cutting-edge and most productive care for those who most need it.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the Urgent and Emergency Care Plan for 2025/26 to tackle corridor care and reduce prolonged A&E waits.
Verbatim wording from the response “In June 2025, we published the Urgent and Emergency Care Plan for 2025/26. The Plan sets out the steps we are taking to tackle corridor care and reduce 12-hour waits in A&E Department’s, including a commitment to eliminate corridor care by improving patient flow. The plan also provides almost £450 million of capital investment including for Same Day Emergency Care and Urgent Treatment Centres. We will provide clear pathways and the right waiting environment when people do need to come to a hospital site with an urgent need. We will take a significant step to separate urgent from emergency care, so that people are treated in the most appropriate setting.” Source location Response from Department of Health and Social Care
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 Provide almost £450 million of capital investment, including funding for Same Day Emergency Care and Urgent Treatment Centres.
Verbatim wording from the response “In June 2025, we published the Urgent and Emergency Care Plan for 2025/26. The Plan sets out the steps we are taking to tackle corridor care and reduce 12-hour waits in A&E Department’s, including a commitment to eliminate corridor care by improving patient flow. The plan also provides almost £450 million of capital investment including for Same Day Emergency Care and Urgent Treatment Centres. We will provide clear pathways and the right waiting environment when people do need to come to a hospital site with an urgent need. We will take a significant step to separate urgent from emergency care, so that people are treated in the most appropriate setting.” Source location Response from Department of Health and Social Care
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 trust is best placed to respond on specific local actions addressing the concerns about prolonged waits, corridor care and operational pressures.
Verbatim wording from the response “The report raises concerns regarding prolonged A&E waits, corridor care and operational pressures faced by Stockport NHS Foundation Trust. I understand that you have also sent a copy of your report directly to the trust who is best placed to respond on the specific actions undertaken locally in response to the concerns you raise. However, in preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 10 Failure to escalate care or make onward referral View source Lack of in-person dietetic assessment recording weight and clinical observations View source Insufficient staff understanding of Medical Emergencies in Eating Disorders guidelines View source Confusion and delayed cascading of Consultant-to-Consultant referral guidance View source Lack of physical face-to-face monitoring of weight View source Lack of scrutiny of reluctance to engage and attend appointments View source Lack of one accessible system for weights, heights and BMI View source Lack of clear accountable oversight of outpatient care View source Failure to provide face-to-face or direct contact before CAMHS discharge View source Failure to share clinically significant eating and weight information with an appropriate body View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
REDACTED Deceased · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
The deceased was a 17-year-old girl with autism, anxiety, significant weight loss and extreme malnutrition who died in hospital on 5 May 2024 after cardiac output was lost following vomiting during preparation for insertion of a central venous line. The principal concerns included inadequate monitoring of her weight, lack of face-to-face assessments, failure to refer or escalate care appropriately, discharge from CAMHS without direct assessment, poor communication and unclear oversight of outpatient care.
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 escalate care or make onward referral
Wider context from the report “4.There was no in person assessment by dietetics or escalation of care
The deceased was assessed via telephone on all occasions. I am concerned that whilst telephone assessments expedited contact there was no in person face to face assessment to record weight or to take and record clinical observations.
At assessment on 2 January 2024, the deceased was not aware of her current weight. A weight history from the 20 November 2023 and a 2022 weight were noted. Her BMI was calculated as 17.
On 5 March 2024 the deceased was reviewed by a specialist dietitian again by telephone. The deceased self-reported her weight to be 33kg with a calculated BMI of 13.4.
The Medical Emergencies in Eating Disorders (MEED) guidelines are used to identify at the earliest stage possible the appropriate care and treatment to be provided. It identifies BMI calculators in the green, amber and red.
Red or high risk would be a BMI less than 13.
The next specialist dietitian review took place on 26 April 2024, 2 weeks later than planned again by telephone. The self-reported weight was 31.8kg with a calculated BMI of 12.9
I am concerned that there was no escalation of care or onward referral , and I am concerned about staff’s understanding of the Medical Emergencies in Eating Disorders (MEED) guidelines.
” 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 in-person dietetic assessment recording weight and clinical observations
Wider context from the report “4.There was no in person assessment by dietetics or escalation of care
The deceased was assessed via telephone on all occasions. I am concerned that whilst telephone assessments expedited contact there was no in person face to face assessment to record weight or to take and record clinical observations .
At assessment on 2 January 2024, the deceased was not aware of her current weight. A weight history from the 20 November 2023 and a 2022 weight were noted. Her BMI was calculated as 17.
On 5 March 2024 the deceased was reviewed by a specialist dietitian again by telephone. The deceased self-reported her weight to be 33kg with a calculated BMI of 13.4.
The Medical Emergencies in Eating Disorders (MEED) guidelines are used to identify at the earliest stage possible the appropriate care and treatment to be provided. It identifies BMI calculators in the green, amber and red.
Red or high risk would be a BMI less than 13.
The next specialist dietitian review took place on 26 April 2024, 2 weeks later than planned again by telephone. The self-reported weight was 31.8kg with a calculated BMI of 12.9
I am concerned that there was no escalation of care or onward referral, and I am concerned about staff’s understanding of the Medical Emergencies in Eating Disorders (MEED) guidelines.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff understanding of Medical Emergencies in Eating Disorders guidelines
Wider context from the report “4.There was no in person assessment by dietetics or escalation of care
The deceased was assessed via telephone on all occasions. I am concerned that whilst telephone assessments expedited contact there was no in person face to face assessment to record weight or to take and record clinical observations.
At assessment on 2 January 2024, the deceased was not aware of her current weight. A weight history from the 20 November 2023 and a 2022 weight were noted. Her BMI was calculated as 17.
On 5 March 2024 the deceased was reviewed by a specialist dietitian again by telephone. The deceased self-reported her weight to be 33kg with a calculated BMI of 13.4.
The Medical Emergencies in Eating Disorders (MEED) guidelines are used to identify at the earliest stage possible the appropriate care and treatment to be provided. It identifies BMI calculators in the green, amber and red.
Red or high risk would be a BMI less than 13.
The next specialist dietitian review took place on 26 April 2024, 2 weeks later than planned again by telephone. The self-reported weight was 31.8kg with a calculated BMI of 12.9
I am concerned that there was no escalation of care or onward referral, and I am concerned about staff’s understanding of the Medical Emergencies in Eating Disorders (MEED) guidelines .
” 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 and delayed cascading of Consultant-to-Consultant referral guidance
Wider context from the report “2.There was no referral to gastroenterology
I am concerned there is confusion as to the guidance on Consultant-to-Consultant referrals .
The Consultant Physician wrote to the GP saying, "please monitor weight loss and refer into gastroenterology services for further assessment".
The GP was aware of guidance regarding Consultant-to-Consultant Referrals that had been updated in October 2023 so that Consultants could and should be directly referring patients themselves to another speciality if there was a clinical reason to do so, rather than passing that task back to the GP. The Consultant Physician told me the guidance was not cascaded down to trust level until December 2023 after the Consultant Physician saw the deceased and that the final guidance has not yet been received .
” 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 physical face-to-face monitoring of weight
Wider context from the report “1.The deceased’s weight was not adequately monitored from November 2023.
I am concerned there was no physical or face to face monitoring of the deceased’s weight from November 2023 . I heard about the importance of physical eye to eye contact and examination on a face-to-face basis so that one can see evidence of the skin, properly see the patient’s face and when doing the height and weight asking for the removal some of their clothing to assess muscle mass.
” 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 scrutiny of reluctance to engage and attend appointments
Wider context from the report “3.The deceased was discharged from CAMHS in December 2023 without being seen in person, spoken to or weighed
The second referral to CAMHs was following the Consultant Physician’s letter dated 20 November 2023. The request was “I would be grateful if you could see this young girl urgently for advice with regards to oral intake. She has lost weight over a number of months and clinical history as outlined above”. The deceased was offered an appointment in keeping with the 4-week national waiting timescale for CYP with an eating disorder.
Contact was made with mum on 24 November and an appointment offered for 13 December 2023. During the call Mum told staff the deceased “hated CAMHS so might kick off and refuse to come”. Mum cancelled the appointment on 11 December 2023.
CAMHS contacted mum by telephone on 12 December 2023. Mum said that the deceased was not aware that she had been referred to CAMHs, was not willing to attend. Again, there was no exploration as to why that was the case and no direct contact with the deceased.
(a) I am concerned the deceased was discharged from CAMHs on 12 December 2023 without being seen face to face or spoken to directly.
(b) I am concerned there was no scrutiny as to why the deceased was reluctant to engage and not attend appointments .
” 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 one accessible system for weights, heights and BMI
Wider context from the report “6.One records system - weights, heights and Body Mass Index (BMI)
I heard that patient care records are held on different care record systems within the NHS which are not universally accessible to healthcare organisations, healthcare professionals or patients. I heard good examples of accessible records such as the Great North Care Record (GNCR) and SystmOne operated by some in Primary Care.
I am concerned there is not one accessible system for weights, heights and BMI .
” 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 accountable oversight of outpatient care
Wider context from the report “6.Oversight of care in an Outpatient setting
There is a lack of clarity regarding oversight of care in an outpatient setting .
The Patient Safety Incident Investigation report identified that there was a lack of oversight of care . The early help assessment team were stepped down in 2022 and they may have been the appropriate team to maintain oversight of care. The SI report comments that the referrals between services were all appropriate but it was unclear who had oversight of all the care and that the investigation team felt that oversight was unclear and that arrangements around risk assessment escalation safeguarding and GP involvement could have been better through improved communication.
I heard that in an inpatient setting there are key NHS standards set around what was described as “the name at the end of the bed” which healthcare professionals work within.
I am concerned that in an outpatient setting there is no specific guidance regarding oversight of care within the NHS. No one department or clinician has overall responsibility or accountability .
” 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 face-to-face or direct contact before CAMHS discharge
Wider context from the report “3.The deceased was discharged from CAMHS in December 2023 without being seen in person, spoken to or weighed
The second referral to CAMHs was following the Consultant Physician’s letter dated 20 November 2023. The request was “I would be grateful if you could see this young girl urgently for advice with regards to oral intake. She has lost weight over a number of months and clinical history as outlined above”. The deceased was offered an appointment in keeping with the 4-week national waiting timescale for CYP with an eating disorder.
Contact was made with mum on 24 November and an appointment offered for 13 December 2023. During the call Mum told staff the deceased “hated CAMHS so might kick off and refuse to come”. Mum cancelled the appointment on 11 December 2023.
CAMHS contacted mum by telephone on 12 December 2023. Mum said that the deceased was not aware that she had been referred to CAMHs, was not willing to attend. Again, there was no exploration as to why that was the case and no direct contact with the deceased.
(a) I am concerned the deceased was discharged from CAMHs on 12 December 2023 without being seen face to face or spoken to directly .
(b) I am concerned there was no scrutiny as to why the deceased was reluctant to engage and not attend appointments.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to share clinically significant eating and weight information with an appropriate body
Wider context from the report “5.The Passage of information/communication
Communication: I heard about the importance of the passage of information. During the course of the inquest a witness was taken to the SEN chronology and an entry dated 1 March 2024 which refers to a conversation with the deceased’s mother on 29 February 2024 where she described the deceased having significant problems with her eating habits, losing weight and refusing to eat foods that would be good for her and put weight on her.
I am concerned that this information was not shared to an appropriate body .
” 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 Execute a programme to improve interoperability and sharing of patient records, including medical history, investigations, height, weight and other vital measurements.
Verbatim wording from the response “It is recognised by NHS England that the joining up of records to achieve easy access to all the information by clinicians and 'patients/their guardians' remains a challenge and NHS England with the Department of Health and Social Care is currently executing a substantial programme of work to increase the interoperability and sharing of all patient records, including medical history, investigations and vital patient measurements (Blood pressure, Height and Weight etc) and would include centile charts in paediatric services. This has been outlined in the Governments 10 Year Plan and the ambition to develop a ‘Single Patient Record’.” Source location Response from Department for Health and Social Care
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 Deliver a Single Patient Record bringing patients’ medical records together in one comprehensive digital record, targeted to begin processing information by 2028.
Verbatim wording from the response “The Government’s 10 Year Health Plan commits to the delivery of a SPR. This will provide a comprehensive patient record, bringing together all of a patient’s medical records into one place which will help prevent unfortunate incidents where fragmented and disjointed information prevents treatment from being provided on time.” Source location Response from Department for Health and Social Care
Open published response
23 Jun 2025 Louise Elizabeth Amy Crane · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Lack of a nationwide policy or approach to anti-ligature measures in mental health settings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Louise Elizabeth Amy Crane · 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
Louise Crane died at Highgate Mental Health Centre on 19 September 2024 from ligature compression to the neck while detained under section 3 of the Mental Health Act. The report identifies concerns about information sharing and recording, risk management, staffing and care and treatment on Topaz Ward, and notes a lack of a nationwide policy or approach to anti-ligature measures in mental health settings.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a nationwide policy or approach to anti-ligature measures in mental health settings
Wider context from the report “1) Evidence from a senior member of North London NHS Trust’s clinical leadership team revealed that there is a lack of a nationwide policy / approach to anti-ligature measures in mental health settings .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing CQC guidance and NHS England safety alerts and guidance are considered sufficient to address ligature-point risks in mental health settings.
Verbatim wording from the response “The Care Quality Commission have issued guidance for providers about reducing harm from ligatures in mental health wards. This can be found at www.cqc.org.uk/guidance-providers/mhforum-ligature-guidance.” Source location Response from Department of Health and Social Care
Open published response
18 Jun 2025 Charlotte Louise ALDERSON · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 4 Lack of expeditiously developed measures for early identification and treatment of sepsis View source Failure of the Interoperability toolkit for information handover between 111 and 999 services View source Inadequacy of the manual telephone backup for critical information handover View source Use of inconsistent infection scoring systems by clinicians View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Charlotte Louise ALDERSON · 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
Charlotte Louise Alderson became seriously unwell from 17 December 2022 and died on 21 December 2022 after a rapidly progressing beta haemolytic streptococcus infection led to septic shock and multi-organ failure. Concerns were raised about the differing outcomes produced by the CENTOR and FEVERPAIN scoring systems, the need for improved tools to identify sepsis or risk of sepsis early, and failures of the NHS Interoperability Toolkit handover between 111 and 999 services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of expeditiously developed measures for early identification and treatment of sepsis
Wider context from the report “b. Evidence received during the Inquest indicated that a number of existing measures within the National Health Service are capable of modification to provide testing tools for the early identification of sepsis/risk of sepsis and which would better inform decisions to prescribe antibiotics . These include CRP, finger prick and lateral flow tests. The risks associated with sepsis and the speed with which a rapid deterioration can occur in patients without clear warning signs of sepsis being present, are well known. There is therefore a need for the expeditious development of measures which assist clinicians in the early identification and treatment of sepsis.
” 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 Interoperability toolkit for information handover between 111 and 999 services
Wider context from the report “c. During the course of the evidence presented at this Inquest, the Court heard that the Interoperability toolkit (ITK) used to handover information between 111 and 999 services will on occasions fail , requiring the manual backup of a telephone call. This was identified as a national issue which, although not frequent, when it occurs carries a significant risk of critical information not being passed due to human error. I am concerned that in such circumstances the manual backup is not adequate and there is a risk that significant information is not passed thereby increasing a risk to life.
” 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 Inadequacy of the manual telephone backup for critical information handover
Wider context from the report “c. During the course of the evidence presented at this Inquest, the Court heard that the Interoperability toolkit (ITK) used to handover information between 111 and 999 services will on occasions fail, requiring the manual backup of a telephone call . This was identified as a national issue which, although not frequent, when it occurs carries a significant risk of critical information not being passed due to human error . I am concerned that in such circumstances the manual backup is not adequate and there is a risk that significant information is not passed thereby increasing a risk to life .
” 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 inconsistent infection scoring systems by clinicians
Wider context from the report “a. There are two scoring systems used by clinicians to assess infection in patients presenting to them, namely; CENTOR and FEVERPAIN. Either may be used by clinicians. Both systems use similar parameters to diagnose and indicate treatment. However, in their application to a given set of circumstances they can produce different outcomes, specifically in relation to the prescription of antibiotics . It is possible in Mrs ALDERSON’s case that the use of the FEVERPAIN scoring system (as opposed to CENTOR) may have made a difference by indicating a prescription for antibiotics, which if taken on the day she was assessed by her GP, may have resulted in a different outcome. There is a need to review these scoring systems, drawing upon the most effective elements of each, with a view to providing guidance on a single scoring system that can consistently be applied by clinicians.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue funding research into the diagnostic accuracy of FeverPAIN and Centor scoring criteria.
Verbatim wording from the response “The Department, through the National Institute for Health and Care Research (NIHR), continues to invest in research to support scoring systems. For example, an NIHR MedTech and In Vitro Diagnostics Co-operative has recently funded research into the diagnostic accuracy of FeverPAIN and Centor criteria for bacterial throat infection. NICE regularly reviews the evidence generated through research such as this with the aim to improve patient outcomes. Additionally, UKHSA is” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fund and support research developing sepsis diagnostics, including point-of-care CRP-VLDL and finger-prick tests.
Verbatim wording from the response “Treatment of sepsis relies on keeping antibiotics working. Developing diagnostics that enable early detection of infections to drive optimal antimicrobial usage is a priority for this government, as set out in the 2024-29 UK antimicrobial resistance national action plan. The government is committed to driving evidence generation to improve our understanding of sepsis diagnosis and immediate management. DHSC continues to fund research through the NIHR and has provided over £21 million in programme funding for sepsis diagnostics and screening since 2020, over £14 million of which was focused on research into sepsis-related diagnostics.” Source location Response from Department of Health and Social Care
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 Manual transfer of information from 111 to 999 mitigates patient-safety risks when the electronic interoperability transfer fails.
Verbatim wording from the response “Finally, you raised concerns regarding system failures of the Interoperability toolkit (ITK) when transferring incident information from 111 to 999 and the associated risks to patient safety. The ITK is an interoperability standard, which sets out how information is securely exchanged from 111 and 999 and was introduced to speed up this transfer. The established procedure for transferring” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NICE is responsible for guidance on clinical processes, including the use of FeverPAIN and Centor scoring systems.
Verbatim wording from the response “I would first like to address your concern regarding the use of the FeverPAIN and Centor scoring systems. As your report outlines, the importance of reliable screening tools to determine the need for antibiotics is tragically evident in this case. NICE is responsible for guidance on clinical processes, including guidance on the use of scoring system diagnostics. The NICE guideline, NG84, on antimicrobial prescribing for acute sore throat recommends that clinicians use FeverPAIN or Centor criteria to identify people who are likely to benefit from an antibiotic. NICE acknowledges that there is currently uncertainty about which scoring system is more effective, and that using either scoring tool in clinical practice is preferential to using neither.” Source location Response from Department of Health and Social Care
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 Current guidance permits either FeverPAIN or Centor because evidence remains uncertain and using either is preferable to using neither.
Verbatim wording from the response “I would first like to address your concern regarding the use of the FeverPAIN and Centor scoring systems. As your report outlines, the importance of reliable screening tools to determine the need for antibiotics is tragically evident in this case. NICE is responsible for guidance on clinical processes, including guidance on the use of scoring system diagnostics. The NICE guideline, NG84, on antimicrobial prescribing for acute sore throat recommends that clinicians use FeverPAIN or Centor criteria to identify people who are likely to benefit from an antibiotic. NICE acknowledges that there is currently uncertainty about which scoring system is more effective, and that using either scoring tool in clinical practice is preferential to using neither.” Source location Response from Department of Health and Social Care
Open published response
12 Jun 2025 Michael Paul Barry · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1 Lack of commissioned specialist services for safely reducing and withdrawing from prescribed dependency-forming medications View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Paul Barry · 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
Michael Paul Barry died at Broomfield Hospital from fatal complications of community-acquired pneumonia, with excessive codeine use contributing to his death. The principal concern was the lack of a commissioned specialist service to help patients and GPs safely reduce or withdraw from prescribed dependency-forming medication, creating a risk of avoidable future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of commissioned specialist services for safely reducing and withdrawing from prescribed dependency-forming medications
Wider context from the report “Notwithstanding the positive finding that the specific medication prescribed by Mr Barry’s GP had not been the source of the excessive codeine taken prior to admission to hospital, compelling evidence was received at the inquest from a Partner at the GP Practice (with a particular specialism in this area of dependency-forming medications) that there remains no specialist commissioned service available for GPs to which they might refer their patients to manage reduction of their intake of prescribed dependency-forming medications . This is in contrast to the availability of commissioned services for patients who are dependent on illicit drugs and/or alcohol.
The evidence confirmed that reduction or cessation of dependency-forming medications needs to be very carefully managed due to the risk of withdrawal symptoms and, in the context of the unchallenged evidence received, requires specialist input and training to maximise the prospects of success and to avoid potentially fatal consequences . The evidence, again unchallenged, was that the continuing absence of such a commissioned service gives rise to the risk of avoidable future deaths .
The long-standing and continuing lack of commissioned services in primary or secondary care for assisting people to safely reduce and withdraw from such prescribed medication was confirmed in her evidence by the Director of Pharmacy and Medicines Optimisation within the Mid and South Essex Integrated Care Board (the ICB). This witness helpfully set out important steps currently proposed and/or being taken to educate clinicians and service users alike of the dangers of opiate based prescription medications (alongside their relatively limited benefits in most, though not all, cases) with a view to reducing the size of the cohort of patients at risk of becoming dependent/addicted in the medium and longer term. However, this does not - absent a commissioned service to which GPs and patients may turn for specialist advice and assistance - address the immediate and on-going risk of future deaths to those currently dependant on/addicted to these medications, with the numbers of such patients having significantly increased in the post-COVID 19 period as a consequence of lengthy delays to, for example, chronic pain-relieving surgery.
Precisely this issue was highlighted in a previous PFD Report from 14th November 2019 issued by the former Senior Coroner in this jurisdiction. The response from the (then) Clinical Commissioning Group had indicated an intention to roll-out a Prescribed Opioid Dependence Local Enhanced Service in early 2020, but this was not implemented due to the COVID 19 pandemic.
Since then, including at the date of Mr Barry’s death in November 2023 and through to today, there remains no such, or similar, commissioned service across Essex or, it appears, consistently across England and Wales with only rare pockets around the country where such a service is commissioned.
” 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 Integrated Care Boards are responsible for commissioning chronic pain and prescribed-medicine withdrawal services for their local populations.
Verbatim wording from the response “Commissioning of services to support people with chronic pain (including services to support people to safely withdraw from prescribed medicines that may cause dependence and withdrawal) now lies with Integrated Care Boards (ICBs). NHS England expects ICBs to commission appropriate services to meet the needs of the population that the ICB geographically covers. This includes taking due regard to any of the above national commissioning or clinical guidance.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England cannot comment on the locally proposed service because it was not nationally commissioned.
Verbatim wording from the response “First, regarding the lack of specialist commissioned services available to GPs, NHS England has advised that the Prescribed Opioid Dependence Local Enhanced Service referenced in your report has been a locally proposed initiative that was not commissioned nationally. Therefore, whilst I do understand your concerns on this matter, NHS England is not able to comment on this specific service.” Source location Response from Department of Health and Social Care
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 Trust cannot provide a stand-alone prescription medication dependency service because it is not commissioned to do so.
Verbatim wording from the response “At present, however, the Trust is not commissioned to provide a specialist service for a stand-alone prescription medication dependency service that would allow direct referral from GPs solely for tapering and withdrawal management of these medicines.” Source location Response from Department of Health and Social Care
Open published response
11 Jun 2025 Lila Airelle Marsland · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Failure to undertake examination or direct assessment before authorising transfer to the Paediatric Emergency Department View source Fragmented and disjointed storage and sharing of clinical information between professionals View source Failure to embed the Child Sepsis Screening Tool in assessment and treatment of children and young people View source Failure to fully implement the latest NICE guideline on bacterial meningitis and meningococcal disease View source Failure to record paediatric examinations in the medical record View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lila Airelle Marsland · 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
Lila Marsland became unwell with headache, fever, lethargy and neck pain and was discharged from hospital with a diagnosis of viral tonsillitis. She was found to have died at home around six and a half hours after discharge; the inquest recorded that she died as a consequence of undiagnosed and untreated pneumococcal meningitis. Concerns included the embedding of the Child Sepsis Screening Tool, implementation of relevant NICE guidance, the adequacy and recording of clinical assessments, and fragmented storage and sharing of clinical information.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake examination or direct assessment before authorising transfer to the Paediatric Emergency Department
Wider context from the report “3. It is a matter of concern that the Locum Consultant in Emergency Medicine who completed a form indicating Lila was ‘Safe to Transfer’ to the Paediatric Emergency Department did so without undertaking any examination or direct assessment of her . The doctor had previously filed a statement at court indicating he had undertaken a ‘preliminary visual assessment’ of Lila, but accepted in oral evidence that this was not, in fact, the case;
” 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 Fragmented and disjointed storage and sharing of clinical information between professionals
Wider context from the report “The court heard evidence that, over the course of almost 10 hours in hospital, Lila’s history and details of examinations and assessments undertaken were recorded on a mixture of various analogue and digital systems in operation in different parts of the Trust, leading to a risk of vital clinical information being lost in the system .
I am concerned that this, and other hospitals elsewhere in the country, continue to operate with information being stored and shared between professionals in a fragmented and disjointed way .
” 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 embed the Child Sepsis Screening Tool in assessment and treatment of children and young people
Wider context from the report “1. Having carefully considered the oral evidence given in court by a range of different clinicians with varying roles and remits, I am concerned that, notwithstanding the work the Trust has undertaken in response to Lila’s death, the Child Sepsis Screening Tool is not yet fully embedded in the minds of those who assess and treat Children and Young People at the Trust ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to fully implement the latest NICE guideline on bacterial meningitis and meningococcal disease
Wider context from the report “2. I am concerned that the Trust is yet to fully implement the latest iteration of the National Institute of Health and Care Excellence’s Guideline Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management (NG240 Published 19 March 2024) ;
” 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 paediatric examinations in the medical record
Wider context from the report “4. I am concerned that no medical record appears to exist of the examination of Lila which was undertaken by the Locum Registrar in Paediatrics which resulted in Lila being discharged from hospital. The absence of this key piece of evidence serves to limit the ability of the Trust to derive all possible learning from Lila’s death.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue rolling out and optimising electronic patient records across NHS trusts to improve access to shared patient information.
Verbatim wording from the response “delivering the best care possible. The Department of Health and Social Care, and NHS England have programmes of work underway which should assist in preventing future deaths connected to this issue.” Source location Response from Department of Health and Social Care
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 Provide support to improve secondary-care organisations’ digital maturity and reduce barriers to sharing clinical information.
Verbatim wording from the response “NHS England is also providing support to bring trusts up to an optimum level of digital maturity, with all secondary care organisations completing a Digital Maturity Assessment in May 2024, which will be run yearly to track progress and identify areas for improvement, which will further reduce barriers to the sharing of information needed to treat patients.” Source location Response from Department of Health and Social Care
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 Run annual digital maturity assessments for secondary-care organisations to track progress and identify improvements.
Verbatim wording from the response “NHS England is also providing support to bring trusts up to an optimum level of digital maturity, with all secondary care organisations completing a Digital Maturity Assessment in May 2024, which will be run yearly to track progress and identify areas for improvement, which will further reduce barriers to the sharing of information needed to treat patients.” Source location Response from Department of Health and Social Care
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 Deliver a single patient record bringing patients’ medical records together, beginning rollout in maternity care from 2028.
Verbatim wording from the response “Going beyond this, the Government’s 10 Year Health Plan commits to delivery of a single patient record (SPR). This will provide a comprehensive patient record, bringing together all of a patient’s medical records into one place. We have been engaging with the public to help shape our plans, including what information they would like to see included in a single patient record and we will continue to talk to the public and to health and care professionals as we design the SPR to ensure their needs are reflected. The SPR will begin to go live from 2028 and be rolled out first in maternity care.” Source location Response from Department of Health and Social Care
Open published response
6 Jun 2025 Frederick Ireland-Rose · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Failure to ensure cannabinoid vape users are aware of the risks posed by nitazenes in vape fluids View source Significant overdose risk from variable nitazene ingestion through vaping View source Limited awareness of nitazenes in vaping fluids View source Limited awareness of or access to Naloxone among cannabinoid vape users View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Frederick Ireland-Rose · 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 Ireland-Rose, who had a history of opiate misuse and had been using cannabinoid vapes, was found unresponsive at home and later died in hospital after sustaining hypoxic-ischaemic brain injury. Toxicology identified the synthetic opioid N-pyrrolidino isotonitazene, and the inquest concluded that his death was drug related. The concerns were that nitazenes in vaping fluids are less well known, vaping exposure can vary substantially with a significant overdose risk, and cannabinoid vape users may be less likely to receive information about these risks or access to Naloxone.
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 cannabinoid vape users are aware of the risks posed by nitazenes in vape fluids
Wider context from the report “(1) The use of nitazenes as an adulterant to street heroin is well known. The presence of nitazenes in vaping fluids is less well known.
(2) The level of nitazenes ingested by vaping will vary enormously depending on the frequency and extent of inhalations taken by the user. Consequently, the potential risk of overdose is significant.
(3) Public health measures are in place through statutory and voluntary sector drug misuse services to inform heroin users of the risks of nitazene adulteration. Cannabinoid vape users will often not be known to drug services and therefore may not be aware of the risks posed by nitazenes in vape fluids.
(4) Drug services often issue Naloxone to be used in the event of an opiate/opioid overdose. Cannabinoid vape users may not be aware of Naloxone or may have problems accessing it.
” 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 Significant overdose risk from variable nitazene ingestion through vaping
Wider context from the report “(1) The use of nitazenes as an adulterant to street heroin is well known. The presence of nitazenes in vaping fluids is less well known.
(2) The level of nitazenes ingested by vaping will vary enormously depending on the frequency and extent of inhalations taken by the user. Consequently, the potential risk of overdose is significant.
(3) Public health measures are in place through statutory and voluntary sector drug misuse services to inform heroin users of the risks of nitazene adulteration. Cannabinoid vape users will often not be known to drug services and therefore may not be aware of the risks posed by nitazenes in vape fluids.
(4) Drug services often issue Naloxone to be used in the event of an opiate/opioid overdose. Cannabinoid vape users may not be aware of Naloxone or may have problems accessing it.
” 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 Limited awareness of nitazenes in vaping fluids
Wider context from the report “(1) The use of nitazenes as an adulterant to street heroin is well known. The presence of nitazenes in vaping fluids is less well known.
(2) The level of nitazenes ingested by vaping will vary enormously depending on the frequency and extent of inhalations taken by the user. Consequently, the potential risk of overdose is significant.
(3) Public health measures are in place through statutory and voluntary sector drug misuse services to inform heroin users of the risks of nitazene adulteration. Cannabinoid vape users will often not be known to drug services and therefore may not be aware of the risks posed by nitazenes in vape fluids.
(4) Drug services often issue Naloxone to be used in the event of an opiate/opioid overdose. Cannabinoid vape users may not be aware of Naloxone or may have problems accessing it.
” 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 Limited awareness of or access to Naloxone among cannabinoid vape users
Wider context from the report “(1) The use of nitazenes as an adulterant to street heroin is well known. The presence of nitazenes in vaping fluids is less well known.
(2) The level of nitazenes ingested by vaping will vary enormously depending on the frequency and extent of inhalations taken by the user. Consequently, the potential risk of overdose is significant.
(3) Public health measures are in place through statutory and voluntary sector drug misuse services to inform heroin users of the risks of nitazene adulteration. Cannabinoid vape users will often not be known to drug services and therefore may not be aware of the risks posed by nitazenes in vape fluids.
(4) Drug services often issue Naloxone to be used in the event of an opiate/opioid overdose. Cannabinoid vape users may not be aware of Naloxone or may have problems accessing it.
” 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 Provide public naloxone information through the FRANK website, including when and how to use it in an emergency.
Verbatim wording from the response “Raising awareness of naloxone and its lifesaving potential among the general public is important. The Government has a drug and alcohol information and advice service called FRANK. This aims to reduce drug and alcohol use and their harms by providing information” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish practical naloxone guidance covering suppliers, products, use, lifesaving tools and required training.
Verbatim wording from the response “Your report also raised concerns about availability of naloxone for cannabinoid vape users. DHSC has an action plan to reduce drug and alcohol-related deaths which includes widening the availability and access to naloxone. Last year, the Government amended the Human Medicines Regulations 2012 to expand access to naloxone. The legislation means more services and professionals can supply this medication without prescription, which in turn means easier access to it for people at risk, and for their loved ones. DHSC has recently published guidance that sets out essential practical information such as who can supply naloxone, the products available, how to use naloxone and other basic lifesaving tools, and the training required.” Source location Response from DHSC
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 Expand naloxone access by enabling additional services and professionals to supply it without prescription.
Verbatim wording from the response “Your report also raised concerns about availability of naloxone for cannabinoid vape users. DHSC has an action plan to reduce drug and alcohol-related deaths which includes widening the availability and access to naloxone. Last year, the Government amended the Human Medicines Regulations 2012 to expand access to naloxone. The legislation means more services and professionals can supply this medication without prescription, which in turn means easier access to it for people at risk, and for their loved ones. DHSC has recently published guidance that sets out essential practical information such as who can supply naloxone, the products available, how to use naloxone and other basic lifesaving tools, and the training required.” Source location Response from DHSC
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 Surveillance indicates nitazene-containing vape liquids are extremely rare, with no confirmed casualties attributed to them.
Verbatim wording from the response “Based on our long-standing surveillance, vape liquids containing nitazenes are extremely rare, with no confirmed casualties attributed. However, fake medicines containing synthetic opioids have become more common and have recently caused several deaths. This has especially been the case among people buying them online for the purpose of selfmedication. The nitazene found in Mr Ireland-Rose’s examination, n-pyrrolidino isotonitazene, is one of a number of common adulterants in fake oxycodone tablets, which are often bought online.” Source location Response from DHSC
Open published response
6 Jun 2025 Esme Vera Louise Atkinson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 10 Lack of audit of the cardiac component of abnormality scans View source Insufficient training of community midwives, health visitors and GPs for early suspicion of heart defects View source Failure to ask all appropriate questions during the 6-8 week GP check View source Failure to store cardiac images from abnormality scans View source Failure to recognise the increased heart-defect risk associated with maternal diabetes when assessing presenting symptoms View source Insufficient sharing of information about feeding and weight loss concerns View source Failure to track infant weight centiles in the early stages View source Insufficient understanding of how to listen for heart defects during the 6-8 week GP check View source Failure of routine echocardiogram protocols to account for relevant genetic heart-defect history View source Lack of routine echocardiograms for babies born to mothers with diabetes View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Esme Vera Louise Atkinson · 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
Esme Vera Louise Atkinson was born on 7 February 2024 and died at Stepping Hill Hospital on 17 March 2024 after suddenly stopping breathing. A post-mortem examination found a ventricular septal defect, and the report states that earlier identification would probably have prevented her death at that time. Concerns included missed opportunities to identify the defect, inadequate recognition of feeding and weight concerns, gaps in professional training and information sharing, and the absence of routine echocardiography and auditing of cardiac images in relevant circumstances.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of audit of the cardiac component of abnormality scans
Wider context from the report “6. Esme had the usual abnormality scan which the inquest was told did not detect the defect on her heart. The inquest was told that the cardiac part of the abnormality scan was not audited in England under national guidance and the cardiac images were not stored. This meant they were not available for subsequent examination.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient training of community midwives, health visitors and GPs for early suspicion of heart defects
Wider context from the report “1. The inquest heard evidence that health visitors /midwives and GPs play a key role in the early identification of a heart defect such as Esme’s at an early stage. Such a defect will rarely be apparent at the 72 hour check on the evidence given at the inquest but symptoms will manifest subsequently. Such symptoms can be subtle and the inquest was told that for there to be early suspicion, of a heart defect, training for community midwives/health visitors and GPs needed to be improved and good quality information sharing was also essential. This should include concerns around feeding and weight loss.
” 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 ask all appropriate questions during the 6-8 week GP check
Wider context from the report “2. The GP check at 6- 8 weeks was a key checking point but needed to be informed by asking all of the right questions and a good understanding of how to listen for such a heart defect.
” 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 store cardiac images from abnormality scans
Wider context from the report “6. Esme had the usual abnormality scan which the inquest was told did not detect the defect on her heart. The inquest was told that the cardiac part of the abnormality scan was not audited in England under national guidance and the cardiac images were not stored . This meant they were not available for subsequent examination .
” 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 the increased heart-defect risk associated with maternal diabetes when assessing presenting symptoms
Wider context from the report “3. The inquest was told that it was important that it was understood by health professionals involved in the care of a baby that the mother being diabetic increased the risk of a defect significantly and should increase the care taken in relation to presenting symptoms .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient sharing of information about feeding and weight loss concerns
Wider context from the report “1. The inquest heard evidence that health visitors /midwives and GPs play a key role in the early identification of a heart defect such as Esme’s at an early stage. Such a defect will rarely be apparent at the 72 hour check on the evidence given at the inquest but symptoms will manifest subsequently. Such symptoms can be subtle and the inquest was told that for there to be early suspicion, of a heart defect, training for community midwives/health visitors and GPs needed to be improved and good quality information sharing was also essential . This should include concerns around feeding and weight loss .
” 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 track infant weight centiles in the early stages
Wider context from the report “7. The evidence of the paediatricians at the inquest was that tracking weight on the centile chart even from an early point assisted in understanding if there was a significant issue in relation to feeding triggering professional curiosity. However the evidence from the Health Visitor appeared to suggest that centile tracking was not seen as useful before 1 month and the red book was not used to look at weight centile tracking in the early stages .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of how to listen for heart defects during the 6-8 week GP check
Wider context from the report “2. The GP check at 6- 8 weeks was a key checking point but needed to be informed by asking all of the right questions and a good understanding of how to listen for such a heart defect .
” 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 routine echocardiogram protocols to account for relevant genetic heart-defect history
Wider context from the report “5. In Esme’s case although her mum’s identical twin had a heart defect this did not in the North West, trigger the protocol for a routine echocardiogram . A heart defect in her mother would have. It was unclear why this was excluded given the genetic link .
” 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 routine echocardiograms for babies born to mothers with diabetes
Wider context from the report “4. There was no routine echocardiogram of a baby born of a mother with diabetes nationally although their risk of a defect was significantly higher than other babies and such a test would detect a baby with a ventricular septal defect at an early stage
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review whether national guidance should require archiving fetal cardiac views from 20-week screening scans.
Verbatim wording from the response “Your report also flagged that the cardiac part of an abnormality scan is not audited in England under national guidance and cardiac images are not stored, meaning they are not available for subsequent examination. Currently there is no NHS FASP requirement to archive images of the fetal cardiac protocol. We acknowledge your concern and NHS England are currently reviewing this and, if required, will revise current guidance on the storage of cardiac views at the 20-week screening scan.” Source location Response from Department of Health and Social Care
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 Digitalise the red book and progressively add information and functionality to improve access to growth and feeding data.
Verbatim wording from the response “Once feeding is established, babies should usually be weighed at around 8, 12 and 16 weeks and 1 year at the time of routine immunisations. We recognise that the red book is an important tool for tracking and sharing information between healthcare professionals, and we are digitalising the red book to improve access to this data. Over time, we will add more information and create more functionality, including AI analytics, to ensure the best care is provided for the child, including detecting any anomalies in weight gain or feeding.” Source location Response from Department of Health and Social Care
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 Use the updated NIPE handbook to support improved congenital heart disease screening practice, including risk factors, examination and result management.
Verbatim wording from the response “Postnatally, the NIPE recommends the offer of screening to all babies born in England for conditions relating to the eyes, heart, hips and testes (if applicable).” Source location Response from Department of Health and Social Care
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 Whether additional fetal echocardiography is offered depends on individual risk assessment and the treating clinician’s discretion.
Verbatim wording from the response “You raised specific concerns that there is no routine echocardiogram of babies born to a mother with diabetes and that in Esme’s case, although her mum’s identical twin had a heart defect, this did not trigger the protocol for a routine echocardiogram. NHS England encourages all trusts to follow the FASP criteria for offering screening for fetal anomalies. Additional screening for fetal anomalies may include a fetal medicine scan and/or a fetal echocardiogram for patients at higher risk of fetal anomalies for such as maternal diabetes, or having a first degree relative with a congenital heart disease (for example an affected parent or sibling). We agree that additional screening for Esme would have been a reasonable course of action, given the increased risk associated with a genetically identical maternal aunt with a heart defect.” Source location Response from Department of Health and Social Care
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations