5 Jun 2025 Colin Charles BROOKS · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1 Failure to provide N+1 onsite perfusionist coverage for simultaneous out-of-hours CPB procedures View source
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Colin Charles BROOKS · Prevention of Future Deaths report
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Report summary
Colin Charles Brooks underwent complex cardiac surgery on 7 May 2024 and developed a hypoxic ischaemic brain injury after blood flow to his brain was compromised during emergency surgery. He remained unresponsive and died in a neurology ward on 11 September 2024. The concern was that out-of-hours staffing and the lack of an additional on-site perfusionist contributed to delayed identification of the missing bridge clamp, creating a risk of similar future deaths.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 N+1 onsite perfusionist coverage for simultaneous out-of-hours CPB procedures
Wider context from the report “1. During the inquest I heard that the emergency surgery on Mr Brooks was taking place out of hours at the same time as another emergency procedure, a lung transplant operation, was taking place in another theatre. The only two on call perfusionists on site were the perfusionist operating the cardiopulmonary bypass machine (“CPB”) in Mr Brooks’s surgery (Perfusionist 2) and the perfusionist involved in the lung transplant operation (Perfusionist 3).
2. The Safety Requirements published by the Society of Clinical Perfusion Scientists in 2023 advises that : “The minimum safe number of accredited clinical perfusion scientists to cover operating theatres for any CPB procedure is deemed as N+1, where N equals the number of operating theatres in use at any given time on a single site. The plus one shall be available onsite ”
3. One of the factors that was, in my view, likely to have contributed to the delay in Perfusionist 2, who was relatively junior in terms of experience, being able to identify the absence of the bridge clamp as the cause Mr Brook’s hypotension, was that Perfusionist 2 was limited in being able to obtain advice from another perfusionist.
4. Contrary to the “N+1” advice, there was no other available perfusionist on site, (apart from Perfusionist 3), whom Perfusionist 2 could call in to the theatre quickly to help with troubleshooting. Perfusionist 3 was unable to leave the theatre next door and so messages had to be exchanged between the two perfusionists which led to the issue being identified.
5. I heard that whilst the “N+1” advice is followed by the UHB Trust during normal working hours, it is not possible for this to be followed out of hours in circumstances where two operating theatres are in operation at the same time owing to resourcing/funding issues and problems with the availability of perfusionists generally , one of the factors being the significant effect staffing this requirement out of hours would have on reducing the waiting lists for surgery during working hours.
6. Although it was a rare event that two emergency procedures requiring a bypass machine were taking place at the same time out of hours, nonetheless there is a risk that future deaths could occur in similar circumstances if action is not taken to address resourcing and the availability of perfusionists.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Determining safe perfusionist staffing levels, including out-of-hours cover, is the responsibility of individual NHS trusts and employers.
Verbatim wording from the response “I have carefully considered the situation. Individual NHS Trusts and other employers are responsible for determining staffing levels and workforce composition. They are best placed to understand their services and the needs of their patients in order to deliver safe and effective care. I would expect University Hospitals Birmingham NHS Foundation Trust and all other NHS Trusts to ensure that their staffing arrangements, including weekend and overnight cover, are appropriate following the tragic death of Mr Brooks.” Source location Response from Department of Health and Social Care
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5 Jun 2025 David Thomas BENDELL · Prevention of Future Deaths report Suffolk
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Concerns raised 1 Lack of a step-down community rehabilitation facility for patients unsuitable for inpatient rehabilitation but unsafe at home View source
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David Thomas BENDELL · Prevention of Future Deaths report
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Report summary
David Bendell fell while trying to use a commode at home after being discharged from hospital following a stroke, and later died in hospital from a large brain bleed. The report raises concern that rehabilitation options limited to specialist inpatient care or treatment at home may place people who cannot safely manage alone at risk when discharged home.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 step-down community rehabilitation facility for patients unsuitable for inpatient rehabilitation but unsafe at home
Wider context from the report “4. In evidence it was heard that David’s condition was such that he was not a candidate for hospital-based rehabilitation on a specialist stroke rehabilitation ward. This meant that the only available treatment option for David was to treat him at home.
5. The court was told that there is no step-down community rehabilitation facility to act as a ‘half way house’ for patients like David, if like David they are not eligible for inpatient rehabilitation, but are in reality not physically capable of keeping themselves safe when alone at home .
6. I am therefore concerned that with the current rehabilitation options available being either in a specialist hospital ward or at home , other individuals in David’s situation who are not deemed suitable for in-patient hospital, will also be placed at risk by being sent home when it is not safe to do so .
” Open source report
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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 stroke services, including rehabilitation.
Verbatim wording from the response “Commissioning of stroke services, including rehabilitation, is the responsibility of Integrated Care Boards (ICB).” Source location Response from Department of Health and Social Care
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3 Jun 2025 Mark Anthony VILLERS · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1 Insufficient radiologist capacity for reporting CT scans View source
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Mark Anthony VILLERS · Prevention of Future Deaths report
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Report summary
Mark Anthony Villers attended hospital with severe chest pain and was later found collapsed and unable to be resuscitated after returning to hospital. A post-mortem examination confirmed death from dissection of the ascending aorta. The report identified missed signs of aortic dissection and insufficient radiologist staffing to report CT scans as substantive concerns.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 radiologist capacity for reporting CT scans
Wider context from the report “1. The investigation by the hospital trust identified that at the time of Mr Villers’ presentation to hospital on 18/05/24 there were insufficient radiologists to report the large number of CT scans undertaken over the weekend period . This was one of the root causes of the very subtle abnormality indicating aortic dissection being missed when the scan was reported. The inquest heard evidence that whilst the situation had improved the number of radiologists was still not in accordance with Royal College of radiology guidelines thus creating a risk of future deaths and in my view, action should be taken.
” Open source report
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How this respondent action was interpreted
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PFD Monitor interpretation Publish a new 10 Year Workforce Plan to support appropriate NHS staffing and workforce distribution.
Verbatim wording from the response “In our 10 Year Health Plan we committed to publishing a new 10 Year Workforce Plan later this year. This will ensure the NHS has the right people in the right places to deliver the best care for patients.” Source location Response from DHSC
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How this respondent position was interpreted
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PFD Monitor interpretation NHS Trusts and other employers are responsible for determining staffing levels and workforce composition, including appropriate weekend cover.
Verbatim wording from the response “I have carefully considered the situation. Individual NHS Trusts and other employers are responsible for determining staffing levels and workforce composition. They are best placed to understand their services and the needs of their patients in order to deliver safe and effective care. I would expect University Hospitals Birmingham NHS Foundation Trust and all other NHS Trusts to ensure that their staffing arrangements, including weekend cover, are appropriate, following the tragic death of Mr Villers.” Source location Response from DHSC
Open published response
3 Jun 2025 Benjamin Finch Arnold · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 6 Unequal provision of maternity services between LGI and SJUH View source Ambiguity about the classification and operating parameters of the SJUH maternity unit View source Limited nursing and medical support available to the SJUH site View source Lack of standardised guidelines for performing LISA procedures View source Insufficient national guidelines for identifying and treating reversible causes of cardiac arrest in newborn babies View source Lack of on-site paediatric cover at SJUH View source See 3 more concerns
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Benjamin Finch Arnold · 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
Benjamin Finch Arnold was born prematurely at Saint James’ University Hospital after his mother was redirected there because the intended delivery unit was closed due to lack of capacity. He developed breathing difficulties during a LISA procedure, suffered bilateral pneumothoraces and a subsequent right-sided tension pneumothorax, and died after a devastating brain injury caused by prolonged low oxygen levels. The concerns included the organisation and classification of maternity services, the lack of standardised guidance for LISA procedures and newborn cardiac arrest, and updates to the hospital risk register.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unequal provision of maternity services between LGI and SJUH
Wider context from the report “(1) The provision of maternity services across the Leeds Teaching Hospitals Trust (LTHT) continues to be split unequally between LGI and SJUH , with, for example, no on-site paediatric cover at SJUH. What was described by LTHT witnesses as the “isolation” of the SJUH site, particularly as it related to the limited nursing and medical support that can be called upon, was a recurrent theme in the inquest. The inquest was told that a long held ambition to bring LTHT’s maternity services under one roof had been recently frustrated by the announcement that the building of a new hospital for Leeds would not begin until 2030. Secretary of State for Health and Social Care to respond.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Ambiguity about the classification and operating parameters of the SJUH maternity unit
Wider context from the report “(2) The evidence at the inquest disclosed an ambiguity as to whether the SJUH maternity unit, officially a “Level 1” centre, was operating outside the parameters of that classification . That ambiguity was demonstrated by a witness (whose evidence was admitted in writing under R23 due to her poor health) who described it as a “Level 2” unit , and by a witness in person who described it as a “Level 1 and a half” unit, which last classification does not exist . LTHT to respond.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 nursing and medical support available to the SJUH site
Wider context from the report “(1) The provision of maternity services across the Leeds Teaching Hospitals Trust (LTHT) continues to be split unequally between LGI and SJUH, with, for example, no on-site paediatric cover at SJUH. What was described by LTHT witnesses as the “isolation” of the SJUH site, particularly as it related to the limited nursing and medical support that can be called upon , was a recurrent theme in the inquest. The inquest was told that a long held ambition to bring LTHT’s maternity services under one roof had been recently frustrated by the announcement that the building of a new hospital for Leeds would not begin until 2030. Secretary of State for Health and Social Care to respond.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 standardised guidelines for performing LISA procedures
Wider context from the report “(3) The evidence disclosed concerns that guidelines for the performing of a LISA procedure are not standardised across the NHS , particularly with reference to the performing of a chest x-ray to exclude pneumothorax before commencing the procedure , and to the necessity of seeking consultant approval before undertaking the procedure . BAPM, RCPCH, RCUK and NN all to respond.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 national guidelines for identifying and treating reversible causes of cardiac arrest in newborn babies
Wider context from the report “(4) The evidence disclosed concerns whether national guidelines on the reversible causes of cardiac arrest (the “4 H’s and 4 T’s”) were sufficient for the purposes of identifying and treating the potential causes of cardiac arrest in a newborn baby . BAPM, RCPCH, RCUK and NN all to respond.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 on-site paediatric cover at SJUH
Wider context from the report “(1) The provision of maternity services across the Leeds Teaching Hospitals Trust (LTHT) continues to be split unequally between LGI and SJUH, with, for example, no on-site paediatric cover at SJUH . What was described by LTHT witnesses as the “isolation” of the SJUH site, particularly as it related to the limited nursing and medical support that can be called upon, was a recurrent theme in the inquest. The inquest was told that a long held ambition to bring LTHT’s maternity services under one roof had been recently frustrated by the announcement that the building of a new hospital for Leeds would not begin until 2030. Secretary of State for Health and Social Care to respond.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a replacement for Leeds General Infirmary as soon as possible.
Verbatim wording from the response “We acknowledge that the ambition of LTHT is to bring all maternity services under one building as part of their new hospital plans, and we are committed to delivering a replacement for LGI as soon as possible. The review of the NHP was necessary to put it on a sustainable footing, however, we recognise that the inclusion of LGI in Wave 2 of the NHP is disappointing for the patients and staff who use and work in LGI.” Source location Response from Department for Health and Social Care
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PFD Monitor interpretation The hospital programme timetable was revised because funding, market capacity, deliverability and clinical-risk prioritisation constrained scheme delivery.
Verbatim wording from the response “We acknowledge that the ambition of LTHT is to bring all maternity services under one building as part of their new hospital plans, and we are committed to delivering a replacement for LGI as soon as possible. The review of the NHP was necessary to put it on a sustainable footing, however, we recognise that the inclusion of LGI in Wave 2 of the NHP is disappointing for the patients and staff who use and work in LGI.” Source location Response from Department for Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual NHS trusts and employers are responsible for ensuring sufficient staffing for safe care and should review staffing levels.
Verbatim wording from the response “Individual NHS Trusts and other employers are responsible for ensuring that there are sufficient staff to provide safe care. I would expect LTHT and other NHS Trusts to review their staffing levels, including in senior roles, to ensure that they are appropriate and in line with BAPM service and quality standards for provision of care in the UK Standards for provision of Neonatal Care in the wake of the death of Benjamin Finch Arnold.” Source location Response from Department for Health and Social Care
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Concerns raised 1 Severe delays in patient handovers at acute hospitals preventing ambulances and crews returning to service View source
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AI-generated summary
Brian GARRICK · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Brian Garrick experienced severe chest pain on 10 August 2022 and was taken to hospital after a substantial ambulance response delay. He suffered a cardiac arrest during a procedure and was pronounced deceased at 1145. The principal concern was that severe delays in patient handovers at acute hospitals were affecting ambulance response times and timely treatment for acute illnesses.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Severe delays in patient handovers at acute hospitals preventing ambulances and crews returning to service
Wider context from the report “I heard evidence from the ambulance trust that on the night in question, despite the volume of calls to the service being at normal levels and crew and vehicle levels being also at normal levels, there were significant delays to ambulance response times due to long hand over times at the local acute hospitals which were preventing ambulances and their crews returning to service .
I heard evidence from the ambulance service that significant action has been taken at a local level by the ambulance and the hospital trusts to try to alleviate the problem and that some progress had been made, but that hand over times were still impacting on service delivery and that as such members of the public are at risk of not receiving timely medical treatment for acute illnesses. I was informed that further progress to be achieved strategic solutions at Governmental level were required to provide an effective solution.
1. Response times for ambulances attending acute medical incidents continue to be impacted by severe delays in patient handovers at acute hospitals preventing ambulances and their crews returning to service.
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve hospital patient flow so at least 78% of A&E patients are seen within four hours and fewer wait over 12 hours.
Verbatim wording from the response “On the 6 June 2025, we published our Urgent and Emergency Care Plan for 2025/26. The Plan focuses on improvements that will see the biggest impact on UEC performance next winter and on making UEC better every day, backed by a total of nearly £450 million of funding. The Plan will:” Source location Response from DHSC
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide capital investment for Same Day Emergency Care, Mental Health Crisis Assessment Centres and new ambulances.
Verbatim wording from the response “On the 6 June 2025, we published our Urgent and Emergency Care Plan for 2025/26. The Plan focuses on improvements that will see the biggest impact on UEC performance next winter and on making UEC better every day, backed by a total of nearly £450 million of funding. The Plan will:” Source location Response from DHSC
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reduce ambulance handovers to a maximum of 45 minutes and Category 2 response times to 30 minutes.
Verbatim wording from the response “On the 6 June 2025, we published our Urgent and Emergency Care Plan for 2025/26. The Plan focuses on improvements that will see the biggest impact on UEC performance next winter and on making UEC better every day, backed by a total of nearly £450 million of funding. The Plan will:” Source location Response from DHSC
Open published response
30 May 2025 Colin David Lovett · Prevention of Future Deaths report Dorset
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Concerns raised 2 Lack of diabetes training and awareness among Prison Service staff View source Unavailability of prison healthcare outside limited operating hours View source
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Colin David Lovett · 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 29 October 2022, Colin David Lovett was found collapsed and unresponsive in his room at HMP The Verne. The report raised concerns about prison staff’s lack of awareness and training regarding diabetes, limited out-of-hours healthcare access, and the support available to prisoners with insulin-dependent diabetes. It also identified concerns about telephone-call monitoring, access to medication, and the adequacy of risk management and support at HMP The Verne.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 diabetes training and awareness among Prison Service staff
Wider context from the report “(1) Evidence was provided by Prison Service staff during the Inquest that they have never received training about diabetes and there is a lack of understanding , and national guidance for Prison Service staff relating to the symptoms of a hypo glycaemic or hyper glycaemic attack, which can be fatal.
(2) The healthcare department at HMP The Verne is only operated between 7.30am and 6pm daily and is not therefore available 24 hours a day. Outside of these operational times, access to healthcare would be via 111 or 999 which could cause delay in action being taken to resolve a hypo glycaemic or hyper glycaemic attack. This will be the position in other prisons nationally.
(3) Whilst insulin dependent diabetics are likely to be experts in their own care, some prisoners may have poorly managed diabetes and require support which could be at any time.
(4) It is acknowledged that there is a balance to be stuck with training non-medical individuals in diagnosing medical symptoms, which could lead to miss diagnosis, and ensuring care is provided without delay, however the Head of Healthcare at HMP The Verne stated that there would be benefit in providing an awareness to Prison Service staff of the impact on prisoners of long term conditions such as diabetes .
(5) Several members of Prison Service staff gave evidence at the Inquest and only one, who had personal experience through a family member, had an understanding of diabetes and the impact it can have upon an individual, including the symptoms of a hypo glycaemic or hyper glycaemic attack .
(6) Prisoners are dependent upon support provided by Prison Staff. I am concerned that the lack of awareness of the needs of prisoners with insulin dependent diabetes amongst Prison Service staff who provide care to prisoners at times when healthcare staff are not on site , 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 Unavailability of prison healthcare outside limited operating hours
Wider context from the report “(2) The healthcare department at HMP The Verne is only operated between 7.30am and 6pm daily and is not therefore available 24 hours a day . Outside of these operational times, access to healthcare would be via 111 or 999 which could cause delay in action being taken to resolve a hypo glycaemic or hyper glycaemic attack . This will be the position in other prisons nationally.
(3) Whilst insulin dependent diabetics are likely to be experts in their own care, some prisoners may have poorly managed diabetes and require support which could be at any time .
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with partners to reduce health inequalities and improve timely, effective healthcare access for people in prison.
Verbatim wording from the response “As signatories to the National Partnership Agreement for Health and Social Care for England, the Department of Health and Social Care and NHS England are committed to working with partners to reduce health inequalities for people in prison and improving services to ensure that people have access to timely and effective healthcare whilst in prison. I would like to inform you that the Chief Medical Officer for England’s report on health in prisons is due to be published this year and will provide recommendations for further action.” Source location Response from Department of Health and Social Care
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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 urgent and out-of-hours healthcare for prisoners.
Verbatim wording from the response “The core hours of healthcare provision are agreed between health and justice commissioners based on local population needs, identified through a comprehensive health needs assessment. The Act states that urgent and out of hours care is the responsibility of integrated care boards for all prisoners. Healthcare providers, supported by NHS England regional health and justice commissioning teams should work with local out of hours and urgent care services to agree effective pathways for any urgent care needs outside of routine healthcare hours.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Training, guidance and diabetes awareness for prison staff are to be addressed by His Majesty’s Prison and Probation Service.
Verbatim wording from the response “In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns related to healthcare services at the prison. Your other concerns regarding issues related to training, guidance and raising awareness of diabetes for prison staff are for the Director General Chief Executive of His Majesty’s Prison and Probation Service to address in their response to you.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Healthcare provision at this Category C prison is required within core hours, considered equivalent to community provision.
Verbatim wording from the response “I understand your concerns about the healthcare services at HMP The Verne not being available 24 hours a day, which could mean delays in action being taken to resolve a hypo glycaemic or hyper glycaemic attack outside of its operational hours. However, this is a Category C prison, and under the Health and Social Care Act 2022, NHS England is required to ensure the provision of healthcare to Category C prisons is within core hours. This is equivalent with community provision.” Source location Response from Department of Health and Social Care
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28 May 2025 Mr Dean Bradley · Prevention of Future Deaths report Teesside and Hartlepool
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Concerns raised 2 Failure to provide adequate safeguarding for intoxicated people before mental health assessment View source Insufficient resources for safeguarding people with mental health illnesses whilst intoxicated View source
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Mr Dean Bradley · 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
Mr Dean Bradley was found deceased by hanging in his hostel flat on 15 October 2021, after earlier suicidal behaviour and expressions of paranoid and persecutory beliefs while apparently under the influence of drugs. Concerns included whether current resources adequately safeguard people with mental health concerns while intoxicated, and failures to contact mental health services and to relay the details of his crisis to hostel staff.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 adequate safeguarding for intoxicated people before mental health assessment
Wider context from the report “2) I heard evidence that a person who was suicidal, suffering with mental health concerns and was intoxicated could not be adequately safeguarded until he was sufficiently sober to allow a mental health assessment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 resources for safeguarding people with mental health illnesses whilst intoxicated
Wider context from the report “1) Current resources for safeguarding those with mental health illnesses whilst intoxicated may be placing people at risk .
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commit £26 million in capital investment to support people experiencing mental health crisis, including new mental health crisis centres.
Verbatim wording from the response “We are also committing £26 million in capital investment to support people in mental health crisis, including opening new mental health crisis centres, which aim to provide accessible and responsive care for individuals in mental health crisis. This builds on the hundreds of alternative crisis services, including crisis cafes, sanctuaries and crisis houses, put in place in recent years, that provide supportive environments outside of traditional clinical settings, and 33 new or improved health-based places of safety.” Source location 2025-0248 Response from Department of Health and Social Care
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The NHS North East and Cumbria Integrated Care Board will respond directly to the concerns.
Verbatim wording from the response “I have noted the contents of your report, and the matters of concern raised. In response, I have liaised with the NHS North East and Cumbria Integrated Care Board (NENC ICB) who will be responding to you directly.” Source location 2025-0248 Response from Department of Health and Social Care
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16 May 2025 Tina Louise DOIG · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1 Insufficient haematology department staffing and capacity for comprehensive reviews View source
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Tina Louise DOIG · Prevention of Future Deaths report
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Report summary
Tina Louise Doig had myelodysplasia that progressed to acute myeloid leukaemia and underwent two stem cell transplants after the first failed. She developed sepsis, multiple organ failure and cardiac arrests, and died after becoming critically unwell. The report identified concern that an understaffed haematology department was working beyond capacity, and described failures in donor-recipient testing before the first transplant.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 haematology department staffing and capacity for comprehensive reviews
Wider context from the report “1. The inquest heard evidence that the haematology department at the time of Mrs Doig’s stem cell transplant was understaffed and working beyond its capacity quite often leaving the team with very little time for comprehensive reviews . ████████ consultant haematologist at University Hospitals Birmingham NHS Foundation Trust confirmed at the inquest that the position remained the same today . This raises a concern that further deaths will occur and action is required.
” Open source report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual NHS trusts and other employers are responsible for ensuring sufficient staffing for safe care.
Verbatim wording from the response “Individual NHS Trusts and other employers are responsible for ensuring that there are sufficient staff to provide safe care. I would expect NHS Trusts and other relevant organisations to review their staffing levels, including in non-patient facing roles, to ensure that they are appropriate in the wake of the death of Mrs Doig.” Source location Response from DHSC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Regulation 18 already requires trusts to review staffing numbers and skills needed to provide safe care.
Verbatim wording from the response “Trusts already have a duty through Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 to regularly review the number of staff and range of skills needed to safely meet the needs of people using their services.” Source location Response from DHSC
Open published response
13 May 2025 Rose Annie Harfleet · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Failure to routinely obtain and listen to parents’ or guardians’ information about children with profound disabilities View source Lack of guidance for managing children with profound disabilities in hospital settings View source Failure to recognise and act on parents’ ongoing concerns about children on hospital wards View source Failure to routinely offer learning disability liaison nurse support in the emergency department View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Rose Annie Harfleet · 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
Rose Annie Harfleet, aged 12, died in hospital on 30 January 2024 after presenting with abdominal pain and vomiting, later identified as a caecal volvulus causing intestinal obstruction and bowel ischaemia. The report raised concerns about failures to recognise and respond to her deterioration, obtain and act on information from her mother, provide appropriate monitoring and surgical review, and offer learning disability liaison support. It also identified a lack of guidance for managing and consulting with children with profound disabilities in hospital settings.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely obtain and listen to parents’ or guardians’ information about children with profound disabilities
Wider context from the report “2. Guidelines - consultation with parents and guardians of children with profound disabilities within a hospital setting
Rose’s mother was devoted to Rose and was very able to advocate on Rose’s behalf as well as being best placed to provide the vital information about her signs and symptoms given Rose was unable to do this for herself. The importance of obtaining this information was not understood by the paediatric consultant who took no history from Rose’s mother and underestimated the severity of her signs and symptoms. The consequence of this was that Rose’s voice – through her mother as her advocate – was not heard and she was not therefore able to actively participate in the care and management that was provided to Rose, the corollary of which resulted in poor clinical decision making which contributed to Rose’s death. This gives rise to a concern that by not listening to parents or guardians as a matter of course leads to discrimination of disabled children.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for managing children with profound disabilities in hospital settings
Wider context from the report “1. The management of children with profound disabilities within a hospital setting
Rose was a deeply loved child who brought great joy to her mother, wider family and all that knew her. During the inquest hearing no national or local guidance was forthcoming to assist medical and nursing staff, within a conventional hospital setting, to appropriately manage patients such as Rose who had a global developmental delay and was wholly reliant on her mother to advocate on her behalf . This gives rise to a concern that this omission adversely impacts the care that patients such as Rose receive.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 and act on parents’ ongoing concerns about children on hospital wards
Wider context from the report “3. Nursing and Medical care on the ward
In the absence of local and national guidelines, the importance of listening and responding to Rose’s mothers ongoing concerns about her daughter when she was transferred to the ward were not recognised by the nursing and medical staff and consequently not acted upon thereby contributing to Rose’s death. There appears to be a prevailing culture that in the absence of a patient being able to explain their symptoms themselves the voice of the parent or guardian is not given the significance it should be for the most vulnerable in a hospital setting.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely offer learning disability liaison nurse support in the emergency department
Wider context from the report “4. LeDeR Role
Rose’s admission was during the working week, yet there was no consideration or offer given to Rose or her mother during her time in the Emergency Department to being introduced to a learning Disability Liaison Nurse . This led to Rose’s mother being unsupported during this admission or for a nursing professional to be able to liaise and advocate for Rose and her mother with medical and nursing staff in the emergency department. This again gives rise to a concern that patients such as Rose and her mother are adversely impacted on the care that they receive in the absence of local and national guidelines that this should be routinely available and offered as a matter of course.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create a single patient record through the NHS App, bringing together patient health information, test results, and letters.
Verbatim wording from the response “As part of the government’s 10-year plan and transforming the NHS from analogue to digital, the government will create a more modern NHS by bringing together a single patient record, summarising patient health information, test results, and letters in one place, through the NHS App. It will put patients and their advocates in control of their own medical history, meaning they do not have to repeat it at every appointment, and that staff have the full picture of patients’ health.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue rolling out Oliver McGowan Mandatory Training on Learning Disability and Autism to the health and adult social care workforce.
Verbatim wording from the response “To improve awareness of learning disability and autism within the health and social care system, under the Health and Care Act 2022, from 1 July 2022 Care Quality Commission (CQC) registered providers are required to ensure their staff receive specific training on learning disability and autism appropriate to their role. This will help to ensure that staff have the right knowledge and skills to provide safe and informed care. To support providers to meet the statutory training requirement, we have been rolling out the Oliver McGowan Mandatory Training on Learning Disability and Autism to the health and adult social care workforce: this specifically highlights the difference that listening to parents can make.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England will address the concern about Learning Disability Liaison Nurses and other relevant actions in a separate response.
Verbatim wording from the response “I will outline actions being taken within the Department to address the first three concerns raised in the report. As NHS England oversees workforce within the NHS, it will address the final concern in its separate response and any other relevant actions on the other concerns raised.” Source location Response from DHSC
Open published response
12 May 2025 Kenneth Foster · Prevention of Future Deaths report East London
View report summary
Concerns raised 1 Failure of governance and safety-review processes to identify, investigate, reflect upon, and remediate sub-optimal practice View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Kenneth Foster · 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
Kenneth Foster, who had epilepsy following a traumatic brain injury in 2012, was admitted to hospital after prolonged seizure activity in September 2024. After interruption of clobazam administration following removal of his naso-gastric tube, his seizures resumed; he was later diagnosed with aspiration pneumonia, which led to his death. The report identified concerns about failures in governance and inadequate incident reporting, morbidity and mortality processes, and Patient Safety Incident Response Framework procedures.
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 governance and safety-review processes to identify, investigate, reflect upon, and remediate sub-optimal practice
Wider context from the report “A. A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice.
In this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trusts are responsible for documenting patient safety incident response decisions and explaining when no specific learning response is undertaken.
Verbatim wording from the response “As such, under PSIRF, not all deaths will be investigated. This will include some which go to inquest. Decision-making regarding patient safety incident response should be documented by Trusts as part of a robust governance process. Where a specific learning response is not undertaken in relation to an incident discussed at inquest, the organisation should be able to explain why this was the case.” Source location 2025-0231-Response from The Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Under PSIRF, not all deaths require investigation; Trusts must document and explain decisions under the existing patient safety incident response governance process.
Verbatim wording from the response “While PSIRF represents a significant improvement to the way that the NHS responds to patient safety incidents, PSIRF does not alter the requirements set out in the National Learning from Deaths policy framework. These require a patient safety incident investigation to be undertaken into any event where problems in care are thought more likely than not to have led to the death of a patient.” Source location 2025-0231-Response from The Department of Health and Social Care
Open published response
Concerns raised 3 Delays in ambulance handover at hospitals View source Insufficient social care provision for patients fit for discharge View source ED crowding delaying care and holding patients in ambulances and corridors View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
JAMES FREDERICK SMITH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Frederick Smith, known as Jim, died on 25 June 2024 at Royal Cornwall Hospital Truro after complications during surgery following a fall and fractured hip. The report identified concerns about insufficient social care provision, significant ambulance handover delays, and emergency department crowding, which increased risks to patients and impeded hospital and ambulance capacity.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover at hospitals
Wider context from the report “(2) Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays and increased mortality risks for patients in the community waiting for emergency ambulances.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 social care provision for patients fit for discharge
Wider context from the report “(1) Insufficient social care provision leading to large numbers of patients in hospital who are otherwise fit for discharge , thereby impeding patient flow through hospital , there being a direct link between inadequate social care provision and ambulance delays.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation ED crowding delaying care and holding patients in ambulances and corridors
Wider context from the report “(3) ED crowding leading to increased risk in mortality for patients being held in ambulances and corridors and being delayed from receiving surgery or specialist treatment on wards .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop local partnership working and increase social care provision to reduce delayed discharges and support timely discharge home.
Verbatim wording from the response “We recognise, then, that more needs to be done to develop local partnership working, increase social care provision and tackle delayed discharges to ensure that patients do not remain in hospital when they are well enough to go home.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Tackle delayed hospital discharges, beginning with patients staying 21 days beyond their discharge-ready date.
Verbatim wording from the response “• tackling the delays in patients waiting to be discharged, starting with those staying 21 days over their discharge-ready-date.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £9 billion through the Better Care Fund in integrated health and social care services during 2025/26.
Verbatim wording from the response “On 31 January 2025, the Government published a revised policy framework for the Better Care Fund (BCF), which took effect on 1 April 2025. Through the BCF, £9 billion are invested in integrated health and social care services in 2025-26, including those to tackle delayed discharges and ensure a timely transition for patients into social care. The objectives of the BCF have been reassessed to put a focus on prioritising preventative care such as early intervention services and community-based support to help people stay healthy and independent and increase patient flow through hospital. The BCF also seeks to bring care closer to home by delivering integrated care in local settings, including people’s homes, to support older adults and those with more complex needs.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide around £450 million in capital funding to expand same-day emergency care and mental health crisis assessment capacity.
Verbatim wording from the response “• capital funding of around £450 million to increase provision of Same Day Emergency Care, Mental Health Crisis Assessment Centres, avoiding unnecessary admissions to hospital and supporting the diagnosis, treatment and discharge on the same day for patients;” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the Urgent and Emergency Care Plan for 2025/26 to improve ambulance response and handover, emergency department performance, and delayed discharge.
Verbatim wording from the response “But we know that we need to start making progress immediately. On 6 June 2025, we published our Urgent and Emergency Care Plan for 2025/26. The plan requires the NHS to focus on those activities that will have the biggest impact on improving urgent and emergency care performance, including ambulance response and handover times:” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and implement the revised Better Care Fund policy framework prioritising preventative, community-based and integrated health and social care services.
Verbatim wording from the response “On 31 January 2025, the Government published a revised policy framework for the Better Care Fund (BCF), which took effect on 1 April 2025. Through the BCF, £9 billion are invested in integrated health and social care services in 2025-26, including those to tackle delayed discharges and ensure a timely transition for patients into social care. The objectives of the BCF have been reassessed to put a focus on prioritising preventative care such as early intervention services and community-based support to help people stay healthy and independent and increase patient flow through hospital. The BCF also seeks to bring care closer to home by delivering integrated care in local settings, including people’s homes, to support older adults and those with more complex needs.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There is no robust evidence directly linking delayed hospital discharges to ambulance handover delays.
Verbatim wording from the response “Whilst high levels of bed occupancy may contribute to ambulance handover delays, hospital discharge delay is one of several factors that contributes to high rates of bed occupancy. We do not have robust evidence linking discharge delays directly to ambulance handover delays. In the NHS Cornwall and the Isles of Scilly Integrated Care Board, in April 2025, the average percentage of adult acute beds occupied by patients remaining despite being medically ready for discharge was 13.5%. For comparison, the average for England at the same period was also 13.5%.” Source location Response from DHSC
Open published response
9 May 2025 Jake Samuel Lawler · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 National asthma scoring system failing to identify exercise-induced asthma View source Failure to revisit and holistically reassess an exercise-related asthma diagnosis View source Limited availability of ECGs for children in community settings View source Lack of clear national guidance on the pathway for children with exercise-induced syncope View source Failure to account for normal resting peak flow readings in patients with exercise-related breathing difficulty View source Failure to recognise the significance of 12-lead ECG readings 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
Jake Samuel Lawler · 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
Jake Samuel Lawler collapsed while playing football on 13 October 2024 and died in hospital on 5 November 2024 after a further collapse. He had been diagnosed with exercise-induced asthma, but his exercise-induced syncope and abnormal ECG were not recognised or acted on appropriately; postmortem examination found biventricular arrhythmogenic cardiomyopathy. The report raises concerns about missed ECG warning signs, unclear pathways for children with exercise-induced syncope, limitations in asthma assessment, and access to ECGs for children in community 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 National asthma scoring system failing to identify exercise-induced asthma
Wider context from the report “3. The diagnosis of exercise induced asthma appeared to be based on a history given at the early stages of his breathlessness being reported to the GP and was not revisited even when he was reporting that the classic treatments were not having a significant impact on his symptoms. This was compounded by the exercise induced syncope being incorrectly linked to asthma.
In addition, Jake was assessed by his GP practice using the national asthma scoring system. However, the scoring system does not appear to facilitate scoring for exercise induced asthma . In Jake’s case the readings and answers pointed to a well-controlled asthma . This was at variance with the fact that his history indicated that he was continuing to struggle with his breathing when exercising and meant he did not trigger as a concern . This was exacerbated by the normal peak flow readings taken at rest which gave a falsely reassuring picture. A lack of curiosity, a lack of appreciation of the limitations of the national scoring system and a non-holistic approach meant that he continued to be seen as asthmatic when all his symptoms were as a result of his undiagnosed Biventricular arrhythmogenic cardiomyopathy
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 revisit and holistically reassess an exercise-related asthma diagnosis
Wider context from the report “3. The diagnosis of exercise induced asthma appeared to be based on a history given at the early stages of his breathlessness being reported to the GP and was not revisited even when he was reporting that the classic treatments were not having a significant impact on his symptoms . This was compounded by the exercise induced syncope being incorrectly linked to asthma .
In addition, Jake was assessed by his GP practice using the national asthma scoring system. However, the scoring system does not appear to facilitate scoring for exercise induced asthma. In Jake’s case the readings and answers pointed to a well-controlled asthma. This was at variance with the fact that his history indicated that he was continuing to struggle with his breathing when exercising and meant he did not trigger as a concern. This was exacerbated by the normal peak flow readings taken at rest which gave a falsely reassuring picture. A lack of curiosity, a lack of appreciation of the limitations of the national scoring system and a non-holistic approach meant that he continued to be seen as asthmatic when all his symptoms were as a result of his undiagnosed Biventricular arrhythmogenic cardiomyopathy
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 availability of ECGs for children in community settings
Wider context from the report “4. ECGs to rule out a possible cardiac issue cannot easily be given to children in a community setting .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clear national guidance on the pathway for children with exercise-induced syncope
Wider context from the report “2. Jake presented with a clear paediatric exercise induced syncope. The inquest was told that there is no clear national guidance on the pathway to be followed in relation to such children although medical training emphasised that this should be treated as a red flag event.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 normal resting peak flow readings in patients with exercise-related breathing difficulty
Wider context from the report “3. The diagnosis of exercise induced asthma appeared to be based on a history given at the early stages of his breathlessness being reported to the GP and was not revisited even when he was reporting that the classic treatments were not having a significant impact on his symptoms. This was compounded by the exercise induced syncope being incorrectly linked to asthma.
In addition, Jake was assessed by his GP practice using the national asthma scoring system. However, the scoring system does not appear to facilitate scoring for exercise induced asthma. In Jake’s case the readings and answers pointed to a well-controlled asthma. This was at variance with the fact that his history indicated that he was continuing to struggle with his breathing when exercising and meant he did not trigger as a concern. This was exacerbated by the normal peak flow readings taken at rest which gave a falsely reassuring picture . A lack of curiosity, a lack of appreciation of the limitations of the national scoring system and a non-holistic approach meant that he continued to be seen as asthmatic when all his symptoms were as a result of his undiagnosed Biventricular arrhythmogenic cardiomyopathy
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 significance of 12-lead ECG readings
Wider context from the report “1. The inquest heard evidence that the significance of 12 lead ECG readings are regularly missed or misunderstood by clinicians which means that key warning signs are missed as in Jake’s case. It is unclear if this is a training issue or the way in which the machines report of volume. Without an improvement there will be further avoidable deaths
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual NHS Trusts and employers are responsible for staff competence and appropriate protocols following the death, rather than the Department.
Verbatim wording from the response “I note your concerns about training and national guidance. Individual NHS Trusts and other employers are responsible for ensuring that staff are, and remain, competent and capable in their area of practice. We would expect NHS Trusts and other relevant organisations to ensure that their protocols are appropriate in the wake of the death of Master Lawler. I note that Manchester University NHS Foundation Trust has considered how to improve both training and guidance as part of their Safety Improvement Plan, which they have shared with NHSE.” Source location 2025-0220- Response from Department of Health and Social Care
Open published response
8 May 2025 James Oliver Sheppard · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 1 Insufficient psychiatric unit bed capacity View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
James Oliver Sheppard · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Oliver Sheppard, who had a history of mental health difficulties, died after diving onto the track in front of a train on 27 June 2023. The principal concern was that there appeared to be insufficient beds available in psychiatric units to meet patient demand.
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 psychiatric unit bed capacity
Wider context from the report “There appear to be insufficient beds available in psychiatric units to meet patient demand
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Shift mental health treatment toward community and crisis services through new care and support models to reduce hospital admissions.
Verbatim wording from the response “As part of our mission to build an NHS fit for the future, we will focus treatment away from hospital and inpatient care and improve community and crisis services, making 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 will hopefully reduce delays, though increasing bed availability, for those who need inpatient care the most.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local trusts, health systems and integrated care boards are responsible for assessing and managing capacity and reducing delays in mental health services.
Verbatim wording from the response “I expect individual trusts and local health systems to effectively assess and manage bed capacity through the ‘flow’ of patients being discharged or moving to another setting.” Source location Response from DHSC
Open published response
Concerns raised 2 Fragmented clinical information systems requiring users to switch between systems View source Failure of multiple clinical systems to support safe transfers of care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John James JOHNSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John James Johnson died on 22 November 2023 after pneumonia developed in the context of squamous cell carcinoma of the right lung. The cancer had been identified on a chest X-ray, but the finding was not followed up, and later treatment options to cure the cancer were unavailable. The substantive concerns included the use of multiple hospital IT systems and the risk that significant findings and information could be overlooked or returned to a department no longer involved in the patient’s 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 Fragmented clinical information systems requiring users to switch between systems
Wider context from the report “(1) During the course of my investigation I heard evidence of the Hospital Trust operating a variety of IT systems to document a patient's stay in hospital. There was not one system which contained all the information generated during a patient’s stay in hospital including, but not limited to, test results. It required clinical users to switch between systems to gather all the necessary information and raised the potential risk of significant findings being overlooked . It also slows down clinical decision making and makes it more difficult to follow a patient's overall care.
(2) In Mr Johnson's case, the X Ray report was returned to a department not then involved in his care. The use of multiple systems can create a risk around safe transfers of care for discharge or handover.
(3) I was told this issue is not confined to one individual Trust and the use of multiple systems is widespread across the National Health Service. Their use is well known to the national NHS responsible bodies.
(4) The Trust in question, has undertaken significant work to make the multiple systems it uses as safe and effective as possible so far as they are able to within their effective control.
(5) Given my concerns are not confined to the operations of one NHS Trust, this appears to be a risk that may be present nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 multiple clinical systems to support safe transfers of care
Wider context from the report “(1) During the course of my investigation I heard evidence of the Hospital Trust operating a variety of IT systems to document a patient's stay in hospital. There was not one system which contained all the information generated during a patient’s stay in hospital including, but not limited to, test results. It required clinical users to switch between systems to gather all the necessary information and raised the potential risk of significant findings being overlooked. It also slows down clinical decision making and makes it more difficult to follow a patient's overall care.
(2) In Mr Johnson's case, the X Ray report was returned to a department not then involved in his care. The use of multiple systems can create a risk around safe transfers of care for discharge or handover.
(3) I was told this issue is not confined to one individual Trust and the use of multiple systems is widespread across the National Health Service. Their use is well known to the national NHS responsible bodies.
(4) The Trust in question, has undertaken significant work to make the multiple systems it uses as safe and effective as possible so far as they are able to within their effective control.
(5) Given my concerns are not confined to the operations of one NHS Trust, this appears to be a risk that may be present nationally.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish the Single Patient Record to unify patient data and provide clinicians with accessible patient information.
Verbatim wording from the response “I agree that ensuring health and care professionals have access to a single source of digital information about the patients they are treating and caring for is vitally important to 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
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Each provider organisation is responsible for sharing information across different digital systems through its established local digital governance processes.
Verbatim wording from the response “Where multiple digital systems, including EPR systems and RIS system are in use across a provider organisation, policies and procedures should be in place to outline expectations, advice, clinical record management, and handover of abnormal results to relevant individuals. Responsibility and accountability for the sharing of information held within electronic records, including across different systems, rests with each organisation through its established digital governance processes.” Source location Response from Department of Health and Social Care
Open published response
2 May 2025 Paul Anthony Burke · Prevention of Future Deaths report Hertfordshire
View report summary
Concerns raised 1 Continuing delays in provision of pre-hospital emergency care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Paul Anthony Burke · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Anthony Burke, aged 41, developed worsening shortness of breath on 19 December 2022 but did not receive an ambulance despite repeated category 2 calls, and was taken to hospital by family. He was later diagnosed with Type 2 Respiratory Failure, deteriorated despite non-invasive ventilation, and died at 07:44hrs on 22 December 2022. The principal concern was the continuing risk of future deaths from delays in providing pre-hospital emergency care, which appeared to be multi-factorial.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Continuing delays in provision of pre-hospital emergency care
Wider context from the report “1. Delay in ambulance response and the consequent delay in the provision of pre-hospital emergency care.
As set out above, Mr Burke first made a call to the ambulance service at 14:07hrs on 19 December 2022. The call was triaged as requiring a category 2 response, requiring a response within an average of 18 minutes, with 90% of calls being responded to within 40 minutes.
I received evidence that category 2 calls are for those whose condition is potentially serious and require rapid assessment, urgent on scene intervention or urgent transport to hospital. By way of example, patients who fall within this category can include those who are unconscious, experiencing chest pain or suffering with stroke symptoms.
Despite the urgency with which an ambulance was required for Mr Burke no ambulance resource was available . It was only due to the intervention of his family who came to his aid that he was able to get to hospital – others may not be so fortunate.
I heard evidence that on 19 December 2022, the local ambulance service was under extreme pressure. At 14:40hrs on 19 December 2022, the ambulance service had a total of 243 outstanding category 2 calls waiting for an ambulance response . 37 of these were within the Hertfordshire area. This was compounded by the fact that 11 ambulances were delayed at Watford General Hospital, one of which had been waiting to handover their patient for over 5 hours. At 18:01hrs on 19 December 2022, this had grown to 315 outstanding category 2 calls waiting for an ambulance response . 47 of these were within the Hertfordshire area. This was compounded by the fact that 9 ambulances were delayed at Watford General Hospital, waiting to hand over patients.
Whilst it is clear that the ambulance service were under extreme pressure on 19 December 2022, on the evidence I heard, this is not an isolated incident. In December of 2022 the average response time for a category 2 ambulance was 61 minutes. In December 2023 the average response time for a category 2 ambulance was 125 minutes. In December 2024 the average response time for a category 2 ambulance was 50 minutes. These times are against a target average response time of 18 minutes.
The East of England Ambulance Service (EEAS) has and continues to take action in conjunction with relevant stakeholders to try and minimise these delays. However, there is only so much they and other parties can do.
On the evidence that I heard the reasons for ambulance delays appear to be multi-factorial and includes issues throughout the wider health system and are issues not unique to Hertfordshire.
In light of the above, I have a concern that is a risk of future deaths occurring due to continuing delays in the provision of pre-hospital emergency care which appear to be multi-factorial in nature.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Set out priorities for developing neighbourhood health services that deliver more care at home or closer to home.
Verbatim wording from the response “In January 2025, we set out priorities for the NHS and local authorities on how to move to a neighbourhood health service that delivers more care at home or closer to home. We are asking local systems to systematically implement six core components of neighbourhood health, which will help people stay healthy and independent for longer and reduce unnecessary time spent in hospital, including tackling hospital discharge delays which will improve patient flow through hospitals and reduce ambulance handover delays.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the 2025/26 Urgent and Emergency Care Plan with measures targeting ambulance response, handover, emergency department performance and same-day care.
Verbatim wording from the response “But we know that we need to start making progress immediately. On 6 June 2025, we published our Urgent and Emergency Care Plan for 2025/26. The plan requires the NHS to focus on those activities that will have the biggest impact on improving urgent and emergency care performance, including ambulance response and handover times:” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ask local systems to systematically implement six core neighbourhood-health components, including measures to reduce discharge and ambulance handover delays.
Verbatim wording from the response “In January 2025, we set out priorities for the NHS and local authorities on how to move to a neighbourhood health service that delivers more care at home or closer to home. We are asking local systems to systematically implement six core components of neighbourhood health, which will help people stay healthy and independent for longer and reduce unnecessary time spent in hospital, including tackling hospital discharge delays which will improve patient flow through hospitals and reduce ambulance handover delays.” Source location Response from DHSC
Open published response
23 Apr 2025 Lorraine Sandra Parker · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 2 Failure to take postoperative CRP results into account in discharge and scanning decisions View source Lack of guidance requiring consideration of CT scanning when CRP is high and not decreasing or rising after major abdominal surgery View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Lorraine Sandra Parker · 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
Lorraine Parker underwent surgery for sigmoid colon cancer in January 2024 and was discharged with a rising CRP and no post-operative scan. After returning to hospital, an anastomotic leak was initially missed, and she later died at Royal Berkshire Hospital on 30 March 2024 following a sudden deterioration. The principal concerns were the lack of guidance requiring consideration of CT scanning when CRP is high and rising or not decreasing, and reliance on clinical judgement without sufficiently accounting for objective blood-test results.
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 take postoperative CRP results into account in discharge and scanning decisions
Wider context from the report “2. There is currently no guidance which requires surgeons to consider scanning for patients who have undergone major abdominal surgery and whose CRP is high and not decreasing, as was the case here at the time Lorraine was discharged from hospital on 31st January 2024.
3. There may be some difficulty in creating a hard line requirement for CT scanning based on a particular CRP result, but I am concerned that there is no guidance in place for requiring a consultant to consider this – perhaps when the CRP is above a certain figure and either not decreasing or continuing to rise. Any such guidance could still allow for clinical judgement – and documenting of the reasons for that decision.
4. It is my experience that clinical judgement alone, particularly where a patient looks well “from the end of the bed” is not always sufficient in this scenario . I have seen a number of avoidable death cases in this context. The purpose of blood test results is to flag up objective areas of concern. There is much reference to chasing up CRP results in Lorraine’s records, but these do not appear to have been taken into account at the time that she was discharged from the hospital without a post-operative scan .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance requiring consideration of CT scanning when CRP is high and not decreasing or rising after major abdominal surgery
Wider context from the report “2. There is currently no guidance which requires surgeons to consider scanning for patients who have undergone major abdominal surgery and whose CRP is high and not decreasing , as was the case here at the time Lorraine was discharged from hospital on 31st January 2024.
3. There may be some difficulty in creating a hard line requirement for CT scanning based on a particular CRP result, but I am concerned that there is no guidance in place for requiring a consultant to consider this – perhaps when the CRP is above a certain figure and either not decreasing or continuing to rise . Any such guidance could still allow for clinical judgement – and documenting of the reasons for that decision.
4. It is my experience that clinical judgement alone, particularly where a patient looks well “from the end of the bed” is not always sufficient in this scenario. I have seen a number of avoidable death cases in this context. The purpose of blood test results is to flag up objective areas of concern. There is much reference to chasing up CRP results in Lorraine’s records, but these do not appear to have been taken into account at the time that she was discharged from the hospital without a post-operative scan.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the case details with NICE’s prioritisation team for consideration of whether further action is needed.
Verbatim wording from the response “The NICE guideline does not provide detailed protocols for postoperative tests or scans, and clinicians would be expected to use their judgement and follow local protocols or other relevant professional guidance. However, whilst the Department has no immediate plans to instruct NICE to produce standalone guidance on post-surgery imaging based on CRP thresholds, details of this case have been shared with colleagues in NICE’s prioritisation team to consider if further action should be taken.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Trusts are responsible for ensuring staff competence and should review their clinical protocols following the case.
Verbatim wording from the response “With regard to concerns about clinical judgement, NHS Trusts are responsible for ensuring staff are sufficiently competent to deliver care. Accordingly, the Trust in question should consider their protocols in the wake of this case. The CQC has passed details of the case to the relevant inspection team for Royal Berkshire Hospital for further consideration.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing NICE guidance, clinical judgement, local protocols and relevant professional guidance are relied upon instead of standalone CRP-based postoperative imaging guidance.
Verbatim wording from the response “With regard to concerns about guidance for clinicians, the NICE guideline on colorectal cancer (NG151) aims to improve quality of life and survival for adults with colorectal cancer by providing evidence-based recommendations on the management of both local disease and metastatic (secondary) cancer. It covers which interventions should be used for different types and stages of the disease, helping to guide decisions on surgery, chemotherapy, and other treatments.” Source location Response from DHSC
Open published response
23 Apr 2025 Christopher Brazil · Prevention of Future Deaths report Ceredigion
View report summary
Concerns raised 7 Lack of dosage guidance View source Unregulated and unlawful online sale of prescription-only medicines and controlled drugs View source Inadequate age and identity verification for access to restricted medicines and drugs View source Exposure of vulnerable and susceptible people to counterfeit or unsafe medications View source Rapid delivery by unlawful online pharmaceutical providers View source Lack of safeguards against incorrect self-diagnosis or consumer misuse View source Insufficient or absent verification of patient medical history before medication sales View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Christopher Brazil · 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
Christopher Brazil had physical pain, sciatica and poor mental health, and sourced additional medicines and drugs from unlawful online providers. He died in August 2022 after unintentionally overdosing on benzodiazepines. The concerns included the accessibility and legitimacy of unregulated websites, unsafe or counterfeit medicines, inadequate checks of medical history, dosage guidance, safeguards, age and identity verification, and rapid delivery.
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 dosage guidance
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unregulated and unlawful online sale of prescription-only medicines and controlled drugs
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs , which look legitimate and are found easily from simple online searches ; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 age and identity verification for access to restricted medicines and drugs
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Exposure of vulnerable and susceptible people to counterfeit or unsafe medications
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Rapid delivery by unlawful online pharmaceutical providers
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 safeguards against incorrect self-diagnosis or consumer misuse
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 or absent verification of patient medical history before medication sales
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase collaboration with UK Border Force to expand border operations and increase seizures of illegally trafficked medicines.
Verbatim wording from the response “Through a combination of public empowerment, technological innovation, traditional methods of law enforcement and close collaboration with partners, the MHRA is constantly working to develop new and innovative ways to tackle the online trade in illegal medicines. Some of these future criminal countermeasures will include:” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out an online service enabling users to check whether pharmaceutical-selling websites have been deemed fraudulent by the MHRA.
Verbatim wording from the response “Through a combination of public empowerment, technological innovation, traditional methods of law enforcement and close collaboration with partners, the MHRA is constantly working to develop new and innovative ways to tackle the online trade in illegal medicines. Some of these future criminal countermeasures will include:” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use technology to identify, track and seize proceeds of crime, including cryptocurrency.
Verbatim wording from the response “Through a combination of public empowerment, technological innovation, traditional methods of law enforcement and close collaboration with partners, the MHRA is constantly working to develop new and innovative ways to tackle the online trade in illegal medicines. Some of these future criminal countermeasures will include:” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use artificial intelligence to proactively identify illicit internet domains for enforcement action.
Verbatim wording from the response “• The use of Artificial Intelligence to proactively identify illicit internet domains for enforcement action.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a web-based scheme allowing users to report suspicious websites, marketplaces and social media listings to the MHRA.
Verbatim wording from the response “• Implementation of a web-based reporting scheme allowing users to report suspicious websites, online marketplaces and social media listings to the MHRA.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enhance collaboration with search engines and UK internet service providers to block harmful content through targeted filtering.
Verbatim wording from the response “Through a combination of public empowerment, technological innovation, traditional methods of law enforcement and close collaboration with partners, the MHRA is constantly working to develop new and innovative ways to tackle the online trade in illegal medicines. Some of these future criminal countermeasures will include:” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Collaborate with Ofcom to explore preventative opportunities under the Online Safety Act.
Verbatim wording from the response “Through a combination of public empowerment, technological innovation, traditional methods of law enforcement and close collaboration with partners, the MHRA is constantly working to develop new and innovative ways to tackle the online trade in illegal medicines. Some of these future criminal countermeasures will include:” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Collaborate with UK banking and payment providers to disrupt payment mechanisms used by illegal prescription-medicine suppliers.
Verbatim wording from the response “• Collaboration with UK banking and payment providers to disrupt the payment mechanisms used by websites illegally supplying prescription only medicines.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation UK authorities cannot seize or control illicit overseas domains or compel registrars to suspend them, especially beyond UK jurisdiction.
Verbatim wording from the response “The sale and supply of unregulated medicinal products is a global problem. Online portals play a significant role in transnational medicines crime and many websites proliferate across the internet. Currently, there is no legal mechanism for UK law enforcement to seize or control of illicit overseas domains or compel internet registrars to suspend them. Gaining regulatory compliance can be a difficult and sometimes impossible process, especially when domains are registered beyond the reach of UK jurisdiction.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The GPhC, other professional regulators, CQC and MHRA have responsibility and powers to investigate unlawful online providers and take enforcement action.
Verbatim wording from the response “In a situation where an online provider acts unlawfully, the General Pharmaceutical Council (GPhC) and other professional regulators, Care Quality Commission (CQC) and the Medicines and Healthcare products Regulatory Agency (MHRA) have the powers to investigate and take action against prescribers, products and suppliers who do not comply with legislation and national guidance. I would like to assure you that regulators have my full support to crack down on any services putting people in danger.” Source location Response from DHSC
Open published response
16 Apr 2025 Abdulrahman AlAjmi · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 3 Absence of systems or structures for safe receipt and treatment of patients arriving in the UK for medical treatment View source Lack of a set procedure for UK hospital acceptance of patients from other countries View source Failure to ensure accurate and updated clinical information for referral acceptance and patient transfer View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Abdulrahman AlAjmi · 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
Abdulrahman AlAjmi died at the London Clinic on 7 August 2024 from multiorgan failure after arriving in the UK for medical treatment in a substantially poorer condition than had been reported. The report found that the flight probably contributed to his death by exacerbating serious pre-existing medical conditions. Concerns included the absence of uniform systems for accepting and transferring overseas patients, ensuring that receiving services have accurate and up-to-date medical information, and safely treating patients who arrive more unwell than anticipated.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of systems or structures for safe receipt and treatment of patients arriving in the UK for medical treatment
Wider context from the report “5. The evidence showed an absence of systems or structures to ensure that patients arriving in the UK for medical treatment are able to be received (by the ambulance transferring them and the hospital treating them) safely and be properly treated : with a full understanding of the accurate and up to date medical position.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a set procedure for UK hospital acceptance of patients from other countries
Wider context from the report “1. In the course of the evidence it was confirmed that there is no set procedure regarding the acceptance by hospitals in the UK of patients for treatment from other countries .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 accurate and updated clinical information for referral acceptance and patient transfer
Wider context from the report “2. It was stated in evidence that patients often arrive in a substantially different (often worse) condition to that described to the receiving clinicians when they accepted the referral and agreed that they were able to provide treatment. This means that UK health providers may receive for treatment individuals who are more unwell than anticipated, potentially requiring expertise that is not held by the receiving treatment providers (albeit in this case they had an ICU team who were able to provide the necessary treatment).
3. The evidence provided showed that it is up to each individual hospital to determine whether they are willing and able to accept a referral and agree the process for transfer of the patient. The evidence indicated that process is not uniform and relies heavily on the accuracy of the information received from the referring medical staff, as well as it being appropriately updated should circumstances change .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Providers have limited recourse to pursue proceedings against medical professionals based in third countries.
Verbatim wording from the response “As noted in the report, there is limited recourse for any provider, NHS or independent, to undertake proceedings against a medical professional based in a third country.” Source location Response from Department for Health and Social Care
Open published response
Concerns raised 3 Failure to provide purchasers with warnings about the risks of high-risk lap belts View source Unrestricted online availability of high-risk healthcare equipment to untrained purchasers View source Failure to provide guidance on professional supervision or fitting of lap belts View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Susan Marion LAKIN · 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 Marion Lakin, a 72-year-old woman with progressive mobility and memory decline, died after sliding beneath an armchair lap belt that became caught around her neck. The report raises concerns that high-risk lap belts were available to purchase online without adequate warnings about risks such as strangulation or guidance from a healthcare professional.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide purchasers with warnings about the risks of high-risk lap belts
Wider context from the report “The advertisement and sales particulars for the lap belt that they purchased states “fits any armchair”, that it provides “extra support to prevent accidents” and finally that it provides “adequate trunk stability avoiding lateral displacements and slides” and “minimises the chance that the patient will... suffer any injuries, tilting or slipping”.
The advertisement and sales particulars contain no warning about the risks that are associated with the use of the lap belt , nor any suggestion that the lap belt should be used or fitted under the guidance/supervision of a therapist or medical professional.
The evidence heard at the inquest was that the lap belt should be considered a “high risk” piece of equipment (it is categorised as such in the local NHS Trust’s Standard Operating Procedure) and that appropriate warnings should be given to those purchasing lap belts in relation to the risks of physical restraint, tissue viability risks and finally the risk of strangulation .
It is concerning that people who have no healthcare training at all can purchase high risk equipment for their loved ones online without being appraised of those risks or even being informed about the high risk nature of the equipment . Lap belts, and other seemingly basic pieces of healthcare equipment, are readily available for people to purchase online without them being appraised of the risks that come with the use of the same.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unrestricted online availability of high-risk healthcare equipment to untrained purchasers
Wider context from the report “The advertisement and sales particulars for the lap belt that they purchased states “fits any armchair”, that it provides “extra support to prevent accidents” and finally that it provides “adequate trunk stability avoiding lateral displacements and slides” and “minimises the chance that the patient will... suffer any injuries, tilting or slipping”.
The advertisement and sales particulars contain no warning about the risks that are associated with the use of the lap belt, nor any suggestion that the lap belt should be used or fitted under the guidance/supervision of a therapist or medical professional.
The evidence heard at the inquest was that the lap belt should be considered a “high risk” piece of equipment (it is categorised as such in the local NHS Trust’s Standard Operating Procedure) and that appropriate warnings should be given to those purchasing lap belts in relation to the risks of physical restraint, tissue viability risks and finally the risk of strangulation.
It is concerning that people who have no healthcare training at all can purchase high risk equipment for their loved ones online without being appraised of those risks or even being informed about the high risk nature of the equipment. Lap belts, and other seemingly basic pieces of healthcare equipment, are readily available for people to purchase online without them being appraised of the risks that come with the use of the same.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 guidance on professional supervision or fitting of lap belts
Wider context from the report “The advertisement and sales particulars for the lap belt that they purchased states “fits any armchair”, that it provides “extra support to prevent accidents” and finally that it provides “adequate trunk stability avoiding lateral displacements and slides” and “minimises the chance that the patient will... suffer any injuries, tilting or slipping”.
The advertisement and sales particulars contain no warning about the risks that are associated with the use of the lap belt, nor any suggestion that the lap belt should be used or fitted under the guidance/supervision of a therapist or medical professional .
The evidence heard at the inquest was that the lap belt should be considered a “high risk” piece of equipment (it is categorised as such in the local NHS Trust’s Standard Operating Procedure) and that appropriate warnings should be given to those purchasing lap belts in relation to the risks of physical restraint, tissue viability risks and finally the risk of strangulation.
It is concerning that people who have no healthcare training at all can purchase high risk equipment for their loved ones online without being appraised of those risks or even being informed about the high risk nature of the equipment. Lap belts, and other seemingly basic pieces of healthcare equipment, are readily available for people to purchase online without them being appraised of the risks that come with the use of the same.
” 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 Write to the Office of Product Safety and Standards expressing concerns about the lap belt product.
Verbatim wording from the response “I will be writing to the Office of Product Safety and Standards with my deep concerns about the product in question. You may also like to make the OPSS aware of your concerns.” 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 Responsibility for concerns about lap belt product advertising, sale, warnings and safety information sits with another organisation.
Verbatim wording from the response “The report raises concerns over the advertisement and sale of the lap belt products which led to Mrs Lakin’s death, and the lack of warning and information around the dangers that could arise from their use. 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 the Medicines and Healthcare products Regulatory Agency (MHRA) is also responding to your report, and I hope that their response will be helpful.” Source location Response from DHSC
Open published response
9 Apr 2025 Bernard Lyon · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 8 Lack of a process to inform families about care home concerns and improvement plans View source Failure of CQC participation in multi-agency care home oversight meetings View source Delays in ambulance handover to the emergency department View source Delays in providing antibiotics in accordance with sepsis needs during high emergency-department demand View source Failure of agency staff to communicate effectively in English with residents and colleagues View source Lack of suitable non-acute or community provision for medically optimised patients View source Lack of sufficient management capacity in the care home View source Insufficient emergency-department bed capacity causing delays in patient transfer 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
Bernard Lyon · 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
Bernard Lyon, who had dysphagia and was living at Hyde Nursing Home, developed sepsis and aspiration pneumonia and died at Tameside General Hospital on 30 January 2024. The report describes concerns about the nursing home's management capacity, staffing and adherence to his modified diet plan, as well as multi-agency oversight, communication with families, ambulance handover delays and delays in administering antibiotics in a very busy 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 a process to inform families about care home concerns and improvement plans
Wider context from the report “4. The inquest was told that there was no process to let a family know of concerns that agencies had about a care home or that it was subject to an improvement plan . This meant that families were being left to make decisions about where to place family members unaware of the actual situation and 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 of CQC participation in multi-agency care home oversight meetings
Wider context from the report “3. The inquest was told that the Local Authority regularly held MAC meetings to look at care home issues from a multi-agency perspective. The CQC was invited but rarely attended the meetings . As a consequence, the flow of information to the CQC was reduced .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover to the emergency department
Wider context from the report “5. The evidence given to the inquest indicated significant delays in the handover from the ambulance to the ED team . This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary and then had a knock-on impact on the ability of the ambulance service to respond to calls. The inquest was told that TGH had made efforts to improve the turnaround time, and it was currently at just an average time of 23.22 minutes. There was further evidence that TGH were not unusual amongst hospitals in the Northwest with the turnaround time at other hospitals running at over 1 hour.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in providing antibiotics in accordance with sepsis needs during high emergency-department demand
Wider context from the report “6. The Emergency Department at TGH was extremely busy on the day Mr Lyon arrived which was not unusual. The sheer volume of patients who were seriously ill meant that there was a delay in him being given antibiotics in accordance with his need . The Trust had taken steps to address this, but it was accepted that where there was a significant demand on an ED compliance with the national sepsis guidance was far more difficult to achieve .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 agency staff to communicate effectively in English with residents and colleagues
Wider context from the report “2. The home relied on agency staff who the inquest was told struggled to have sufficient grasp of the English language to understand instructions given and to communicate with residents .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 non-acute or community provision for medically optimised patients
Wider context from the report “7. The inquest was told that the build-up of patients and levels of demand in the ED at TGH were not unusual and continued. As an illustration of the ongoing nature of the demand in recent months one patient has waited in ED for 3 days for a bed. The delay in transfer was due to an ongoing demand for beds and delayed discharges of patients medically optimised but with no suitable non acute/community provision being available .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 sufficient management capacity in the care home
Wider context from the report “1. The care home in question was recognised as having too few managers for it to be effectively managed but was allowed to continue to operate and was seeking to expand
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 emergency-department bed capacity causing delays in patient transfer
Wider context from the report “7. The inquest was told that the build-up of patients and levels of demand in the ED at TGH were not unusual and continued. As an illustration of the ongoing nature of the demand in recent months one patient has waited in ED for 3 days for a bed. The delay in transfer was due to an ongoing demand for beds and delayed discharges of patients medically optimised but with no suitable non acute/community provision being available.
” 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 Promote adult social care careers to jobseekers through recruitment support with the Department for Work and Pensions.
Verbatim wording from the response “The government recognises the scale of reforms needed to make sure the ASC sector has sustainable workforce growth and improve the retention of the domestic workforce. This is why we are working with the Department of Work and Pensions (DWP) to promote ASC careers to jobseekers. DWP supports employers in the ASC sector with their recruitment through a range of activities including Jobs Fairs, hosting employers in Jobcentres and promoting their vacancies. We are also introducing the first ever Fair Pay Agreement for care professionals and expanding the Care Workforce Pathway (the first-ever national career structure for ASC) which outlines a structured route for care workers to move into management roles. It helps care homes identify and nurture internal talent by showing staff how to advance from entry-level roles to registered manager positions.” 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 guidance for social care providers on international recruitment and assessing care workers’ English-language competence.
Verbatim wording from the response “To support providers, the department published the ‘International recruitment toolkit for social care providers’ (International recruitment toolkit - March 2024), outlining the English language requirements and steps employers should take during the recruitment process to ensure care workers have the correct level of English language competence.” 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 the Care Workforce Pathway to support progression into adult social care management.
Verbatim wording from the response “The government recognises the scale of reforms needed to make sure the ASC sector has sustainable workforce growth and improve the retention of the domestic workforce. This is why we are working with the Department of Work and Pensions (DWP) to promote ASC careers to jobseekers. DWP supports employers in the ASC sector with their recruitment through a range of activities including Jobs Fairs, hosting employers in Jobcentres and promoting their vacancies. We are also introducing the first ever Fair Pay Agreement for care professionals and expanding the Care Workforce Pathway (the first-ever national career structure for ASC) which outlines a structured route for care workers to move into management roles. It helps care homes identify and nurture internal talent by showing staff how to advance from entry-level roles to registered manager positions.” 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 revised Better Care Fund policy framework and commit approximately £9 billion for 2025–26 discharge-related activity.
Verbatim wording from the response “More broadly, this government is committed to tackling delayed discharges through the Better Care Fund (BCF), and its revised policy framework, published on 31 January 2025. For 2025-26, approximately £9 billion is committed to the BCF. This includes around £3.3 billion provided to local authorities and £5.6 billion to integrated care boards, both of which” 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 greater transparency of care-home CQC action plans for families.
Verbatim wording from the response “Your request found that there is currently no process in place for routinely communicating to families when a care home is subject to a CQC action plan. Action plans are documents which CQC ask a provider to produce when significant concerns are identified at a service. The action plan is produced by and is the responsibility of the provider – CQC receive it for awareness and monitoring purposes. Action plans can already be made publicly available, if requested through the provision of the Freedom of Information Act (FOIA). When CQC receive FOIA requests for action plans, they consider the public interest in disclosure on a case-by-case basis.” 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 CQC will address concerns about its attendance at multi-agency care home meetings separately.
Verbatim wording from the response “3) CQC not attending MAC meetings – this will be addressed by the CQC separately.” 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 care provider is responsible for assessing agency staff’s English proficiency and ensuring their suitability for the role.
Verbatim wording from the response “Furthermore, there are immigration routes which permit individuals to work in the UK without needing to seek approval from the Home Office and do not have an English language requirement. Care providers are therefore responsible for ensuring that the individual speaks and reads to the standard required for the job.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 22 Failure of child death review to identify learning across relevant environmental and service factors View source Uncertainty about learning identified through paediatric mortality review View source Lack of funding mechanisms enabling cardiac screening for competitive boxers View source Failure to obtain echocardiography for critically unwell patients in shock View source Failure to target intravenous fluid management against patient response View source Failure to retain emergency department monitor data for retrospective analysis View source Failure to undertake deep-dive safety audits examining patterns and trends View source Delays in obtaining the first blood gas View source Deficiencies in ECG interpretation View source Failure to formulate a differential diagnosis View source Lack of parental awareness of sudden cardiac death red-flag symptoms View source Insufficient radiologist capacity for expanding imaging demand View source Failure of communication within and between clinical teams View source Insufficient clinical knowledge of medication effects and pharmacologic consequences View source Lack of funding and implementation of defined cardiogenic shock escalation and care pathways View source Failure to embed HSSIB critically unwell patient guidance in staff training View source Lack of recorded assessment of radiological images View source Lack of recorded evidence on key aspects of patient care View source Insufficient critical care training View source Insufficient critical care resources View source Insufficient audit of sepsis pathway use View source Insufficient sepsis pathway training View source See 19 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Christian James Gabriel Hobbs · 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
Christian James Gabriel Hobbs, a 17-year-old, suffered an acute deterioration at home and was taken to hospital on 26 December 2017, where he developed cardiac arrest and died after treatment was stopped. The inquest recorded multi-organ failure, cardiogenic shock and arrhythmogenic cardiomyopathy. Concerns included the absence of an echocardiogram before his arrest, non-targeted fluid management, delays in obtaining blood gases, team communication, radiology documentation, differential diagnosis, ECG interpretation, record keeping and emergency-department alarm data retention.
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 child death review to identify learning across relevant environmental and service factors
Wider context from the report “POINT R – CHILD DEATH OVERVIEW PANEL REVIEW
Whilst the death occurred in Cambridgeshire, it is understood that the Northamptonshire CDOP reviewed this matter. However, it appears that a copy of the Analysis Proforma is not available but taking information from a collation of reviews, there was no identification of any learning in terms of factors intrinsic to the social environment, physical environment or service provision .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about learning identified through paediatric mortality review
Wider context from the report “POINT S – NWAFT PAEDIATRIC MORTALITY REVIEW
It is unclear whether any NWAFT paediatric review found any issues from a learning perspective given the matters analysed at length within the coronial investigation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 funding mechanisms enabling cardiac screening for competitive boxers
Wider context from the report “POINT Q – TESTING IN COMPETITIVE SPORTS FOR CARDIAC CONDITIONS
I have a concern about funding mechanisms being available to say England Boxing that would enable appropriate screening for competitive boxers where there is already a mandatory need for a medical examination under the ‘fit or not fit to box’ protocol. This would aid further research on this important topic.
Additionally, there may be a lack of general awareness for parents of sports participants on the issue of sudden cardiac death and so there may be a gap in knowledge/understanding of possible emergence of red flag 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 Failure to obtain echocardiography for critically unwell patients in shock
Wider context from the report “POINT B - RE: ECHOCARDIOGRAPHY
Christian had not had an echocardiogram prior to his arrest . This was a concerning feature of his care in the ED given he was critically unwell and in a shocked state .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to target intravenous fluid management against patient response
Wider context from the report “POINT C - FLUID MANAGEMENT
Intravenous fluids were commenced but these were not targeted against response . Christian remained hypotensive and tachycardic despite the fluid administration. This is an area of concern also.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to retain emergency department monitor data for retrospective analysis
Wider context from the report “POINT N - DATA FROM EMERGENCY DEPARTMENT ALARMS
The monitor evidence was not available for analysis of heart rhythms etc because there was no retention of the data at the time . This hampered consideration of data in the death that required detailed review and this is a 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 undertake deep-dive safety audits examining patterns and trends
Wider context from the report “POINT P - PATIENT SAFETY IN SOME TRUST AREAS
This is a concern and it is unclear as to whether there has been a deep dive audit/review to look at patterns/trends rather than simply looking at raw overall mortality data .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining the first blood gas
Wider context from the report “POINT G – BLOOD GASES/ ELEVATED LACTATE
There was a delay in getting the first blood gas . A cannula was in situ by circa 19:00, when intravenous fluids and antibiotics were given. A venous blood gas should have been taken from this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in ECG interpretation
Wider context from the report “POINT L – ECG ANALYSIS
Some Issues emerged in evidence on the interpretation of the ECG at 18:10.
This again raises 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 formulate a differential diagnosis
Wider context from the report “POINT I - DIFFERENTIAL DIAGNOSIS
A recurring theme is lack of a differential diagnosis which raises concerns about training.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 parental awareness of sudden cardiac death red-flag symptoms
Wider context from the report “POINT Q – TESTING IN COMPETITIVE SPORTS FOR CARDIAC CONDITIONS
I have a concern about funding mechanisms being available to say England Boxing that would enable appropriate screening for competitive boxers where there is already a mandatory need for a medical examination under the ‘fit or not fit to box’ protocol. This would aid further research on this important topic.
Additionally, there may be a lack of general awareness for parents of sports participants on the issue of sudden cardiac death and so there may be a gap in knowledge/understanding of possible emergence of red flag 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 radiologist capacity for expanding imaging demand
Wider context from the report “POINT F - RADIOLOGY NATIONALLY
I have a concern over whether there are sufficient numbers of radiologists to cover the ever-increasing expansion of imaging as a key diagnostic tool.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of communication within and between clinical teams
Wider context from the report “POINT D - TEAM INTERACTIONS
A concern arises over communications within a team itself and also interactions with other teams – e.g. when a referral is made to the medical team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 clinical knowledge of medication effects and pharmacologic consequences
Wider context from the report “POINT K- ANTIEMETIC MEDICATION
I have a concern on clinical knowledge of such effects of this drug and pharmacologic consequences of other drugs also .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 funding and implementation of defined cardiogenic shock escalation and care pathways
Wider context from the report “POINT A - RE: CARDIOGENIC SHOCK CS)
I have a concern over funding availability and implementation of the key recommendations set out below.
The Intensive Care Society and British Cardiovascular Society issued a comprehensive report in October 2022 with the title - Shock to Survival: a framework to improve the care and outcomes of people with cardiogenic shock in the UK.
The Executive Summary reported that patients with cardiogenic shock need defined pathways of escalation and care to improve survival .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 HSSIB critically unwell patient guidance in staff training
Wider context from the report “POINT O – LEARNING FROM HSSIB REPORTS
I have a concern on whether the HSSIB report – RECOGNISING AND RESPONDING TO CRITICALLY UNWELL PATIENTS is firmly embedded in staff training .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 recorded assessment of radiological images
Wider context from the report “POINT E – RADIOLOGY WITHIN NWAFT
Another recurring theme is radiology within the trust. In the case of Christian, nothing is recorded in the notes on assessment of the X-Rays undertaken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 recorded evidence on key aspects of patient care
Wider context from the report “POINT M -RECORD KEEPING
There was a lack of recorded evidence on key aspects of Christians care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient critical care training
Wider context from the report “POINT H - CRITICAL CARE
There are concerns about resources and training within the trust for this specialty .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 critical care resources
Wider context from the report “POINT H - CRITICAL CARE
There are concerns about resources and training within the trust for this specialty .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 audit of sepsis pathway use
Wider context from the report “POINT J - SEPSIS PATHWAY
This is again another theme and accordingly raises a concern about training and auditing .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 sepsis pathway training
Wider context from the report “POINT J - SEPSIS PATHWAY
This is again another theme and accordingly raises a concern about training and auditing .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a new 10 Year Workforce Plan later this year.
Verbatim wording from the response “In our 10 Year Health Plan we commit to publishing a new 10 Year Workforce Plan later this year. This will ensure the NHS has the right people in the right places to deliver the best care for patients.” 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 NHS Trusts and other relevant organisations are responsible for ensuring their protocols are appropriate after the death.
Verbatim wording from the response “I would further expect NHS Trusts and other relevant organisations to ensure that their protocols are appropriate in the wake of the death of Master Hobbs.” 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 Universities, Medical Royal Colleges and the GMC are responsible for setting, approving and maintaining medical curricula and postgraduate training standards.
Verbatim wording from the response “We understand and appreciate the findings that adverse effects of antiemetics, namely cardiovascular effects may have had an impact. Universities are responsible for setting their own medical curricula, which must meet GMC standards. Postgraduate curricula are set by Medical Royal Colleges and are approved by the GMC.” 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 NHS Trusts and other employers are responsible for ensuring staff remain competent and capable in their areas of practice.
Verbatim wording from the response “On points F, K, and L, where you raise issues of workforce levels and training, individual NHS Trusts and other employers are responsible for ensuring that staff are, and remain, competent and capable in their area of practice.” Source location Response from Department for Health and Social Care
Open published response
4 Apr 2025 Mr Alexi Susiluoto · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to include homelessness-related care issues in the review of treatment for patients with dual diagnoses View source Fragmented provision of substance misuse and mental health treatment across different organisations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Alexi Susiluoto · 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
Mr Alexi Susiluoto, who had a history of mental health disorders, substance misuse and epilepsy, was found deceased in a hotel room on 22 May 2024. His death was attributed to alcohol misuse disorder resulting in acute ethanol toxicity, with epilepsy and prescribed medication as contributing factors. The report raised concerns about fragmented care for people with dual diagnoses who are homeless, including confusion over which services and local authority were responsible for care and funding.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to include homelessness-related care issues in the review of treatment for patients with dual diagnoses
Wider context from the report “1. I heard evidence that the Office for Health Improvement and Disparities is currently undertaking a review of how patients with dual diagnoses (substance misuse and mental health disorders) are treated. I was concerned by two related issues:
a. That substance misuse and mental health treatment is routinely provided by different organisations, despite close interplay between these conditions and that this can result in significant complexities for agencies caring for the same patient. I understand that this aspect is part of the current review;
b. However, I also heard that the review is not taking into consideration the additional issues that arise when a patient with dual diagnoses is also homeless . Evidence presented at the inquest set out that this already complex situation is often compounded by homelessness, since individuals are often moved between temporary accommodation and therefore between different mental health trust and substance misuse providers. In Mr Susiluoto’s case, this resulted in significant confusion as to who was providing his care and which local authority would fund potential substance misuse treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Fragmented provision of substance misuse and mental health treatment across different organisations
Wider context from the report “1. I heard evidence that the Office for Health Improvement and Disparities is currently undertaking a review of how patients with dual diagnoses (substance misuse and mental health disorders) are treated. I was concerned by two related issues:
a. That substance misuse and mental health treatment is routinely provided by different organisations , despite close interplay between these conditions and that this can result in significant complexities for agencies caring for the same patient . I understand that this aspect is part of the current review;
b. However, I also heard that the review is not taking into consideration the additional issues that arise when a patient with dual diagnoses is also homeless. Evidence presented at the inquest set out that this already complex situation is often compounded by homelessness, since individuals are often moved between temporary accommodation and therefore between different mental health trust and substance misuse providers. In Mr Susiluoto’s case, this resulted in significant confusion as to who was providing his care and which local authority would fund potential substance misuse treatment.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a comprehensive action plan to improve provision for people with co-occurring substance-use and mental-health needs.
Verbatim wording from the response “Your report mentions a review my department is taking into treatment for people with substance use and mental health conditions, and you raise concerns that the review is not considering the additional complexities and issues that occur when someone is also experiencing, or at risk of, homelessness. My department recognises the vital importance of high-quality integrated care for those with co-occurring conditions and who sleep rough, or who are at risk of sleeping rough. To clarify, we have not undertaken a formal review but, following recommendation from Dame Carol Black’s independent review of drugs, have been developing a comprehensive action plan to set out a path to improving service provision for those with co-occurring substance use and mental health needs.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with NHS England to improve integrated care for people with substance-use and mental-health needs.
Verbatim wording from the response “Thank you for bringing these concerns to my attention. I want to assure you my department and NHSE recognise these issues and are continuing to work closely together to improve integrated care for those with substance use issues. I hope this response is helpful.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish UK clinical guidelines on alcohol treatment, including recommendations for co-occurring conditions, multidisciplinary assessment, care planning and care coordination.
Verbatim wording from the response “- DHSC will soon publish the UK clinical guidelines on alcohol treatment to support and improve the quality of treatment for people with alcohol dependence. The guidelines include chapters on working with people with co-occurring alcohol dependence and mental health and/or physical health conditions. They also include recommendations on multi-disciplinary assessment, care planning and care co-ordination.” Source location Response from DHSC
Open published response
Concerns raised 3 ED crowding delaying patient access to surgery or specialist treatment View source Delays in ambulance handover View source Insufficient social care provision for patients fit for discharge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Andrew Waters · 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 Waters died at Royal Cornwall Hospital on 24 May 2024 after experiencing symptoms of a heart attack and a delay in receiving an ambulance. He went into cardiac arrest shortly after arriving at hospital, and the inquest found that the ambulance delay, attributed to systemic failure across health and social care, possibly denied him potentially lifesaving treatment. The principal concerns were significant ambulance handover delays, emergency department crowding, and insufficient social care provision affecting patient flow.
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 ED crowding delaying patient access to surgery or specialist treatment
Wider context from the report “(2) ED crowding leading to increased risk in mortality for patients being held in ambulances and corridors and being delayed from receiving surgery or specialist treatment on wards .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover
Wider context from the report “(1) Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 social care provision for patients fit for discharge
Wider context from the report “(3) Insufficient social care provision leading to large numbers of patients in hospital who are otherwise fit for discharge , thereby impeding patient flow through hospital .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Set out lessons learned from winter urgent and emergency care pressures.
Verbatim wording from the response “In addition, we will also shortly set out the lessons learned from the pressures on urgent and emergency care services this winter and the improvements that we will put in place to further improve services during 2025/26.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen NHS and social care partnerships to tackle delayed discharges, reduce hospital stays and free beds.
Verbatim wording from the response “Turning to the issue of delayed patient discharges, the government is tackling delayed discharges to reduce hospital stays and free up beds by strengthening NHS and social care partnerships.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the new £9 billion Better Care Fund policy framework establishing joint NHS and local-authority accountability for reducing discharge delays.
Verbatim wording from the response “In January 2025, we also published a new policy framework for the £9 billion Better Care Fund. Under the new framework, the NHS and local authorities have clear accountability for setting and achieving joint goals that include reducing discharge delays.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ask local systems to implement six neighbourhood-health components, including measures to reduce hospital discharge delays.
Verbatim wording from the response “In January 2025, we set out priorities for the NHS and local authorities on how to move to a neighbourhood health service that delivers more care at home or closer to home. We are asking local systems to systematically implement six core components of neighbourhood health, which will help people stay healthy and independent for longer and reduce unnecessary time spent in hospital, including tackling hospital discharge delays.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the 2025 mandate to NHS England, prioritising improvements to A&E and ambulance waiting times.
Verbatim wording from the response “On 30 January 2025, the Government published ‘Road to recovery: the government's 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Put improvements in place to further improve urgent and emergency care services during 2025/26.
Verbatim wording from the response “In addition, we will also shortly set out the lessons learned from the pressures on urgent and emergency care services this winter and the improvements that we will put in place to further improve services during 2025/26.” Source location Response from DHSC
Open published response
Concerns raised 2 Lack of guidance for assessing when external intervention can be triggered View source Failure of mental capacity assessment guidance to recognise Executive Dysfunction View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Loraine Michelle CHEESMAN · 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
Loraine Michelle CHEESMAN died in Darlington on 13 May 2023 as a consequence of a fire at the property. Her Hoarding Disorder and Executive Dysfunction made a more than minimal contribution to the fire, and concerns were raised about the lack of specific guidance on incorporating Executive Dysfunction into mental-capacity assessments and determining when external intervention should be triggered.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for assessing when external intervention can be triggered
Wider context from the report “Department of Health and Social Care (2023), Care and Support Statutory Guidance, Section 14.17 states in relation to Self Neglect and Hoarding Disorder:
“‘This covers a wide range of behaviour neglecting to care of one’s personal hygiene, health or surroundings and includes behaviour such as hoarding. It should be noted that self-neglect may not prompt a section 42 enquiry. An assessment should be made on a case by case basis. A decision on whether a response is required under safeguarding will depend on the adult’s ability to protect themselves by controlling their own behaviour. There may come a point when they are no longer able to do this, without external support.”
During the course of the evidence I heard from social workers and safeguarding professionals than in relation to assessing whether “the point” had been reached in relation to an adult suffering from Hoarding Disorder and Executive Dysfunction there was no specific guidance and that such guidance would in future be welcome. Currently they are constrained by existing guidance for assessing mental capacity, which does not directly recognise Executive Dysfunction, or for assessing whether the adult’s behaviour constitutes a potentially chargeable criminal or regulatory offence, for example in relation to public nuisance, health hazard, or anti social behaviour, rather than the root cause of the behaviour - a mental disorder or disorders.
So, the matter of concern consists of this request - for guidance to be provided as to how to incorporate consideration of Executive Dysfunction into the assessment of mental capacity and how to assess when the point when external intervention can be triggered has been reached.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 mental capacity assessment guidance to recognise Executive Dysfunction
Wider context from the report “Department of Health and Social Care (2023), Care and Support Statutory Guidance, Section 14.17 states in relation to Self Neglect and Hoarding Disorder:
“‘This covers a wide range of behaviour neglecting to care of one’s personal hygiene, health or surroundings and includes behaviour such as hoarding. It should be noted that self-neglect may not prompt a section 42 enquiry. An assessment should be made on a case by case basis. A decision on whether a response is required under safeguarding will depend on the adult’s ability to protect themselves by controlling their own behaviour. There may come a point when they are no longer able to do this, without external support.”
During the course of the evidence I heard from social workers and safeguarding professionals than in relation to assessing whether “the point” had been reached in relation to an adult suffering from Hoarding Disorder and Executive Dysfunction there was no specific guidance and that such guidance would in future be welcome. Currently they are constrained by existing guidance for assessing mental capacity, which does not directly recognise Executive Dysfunction , or for assessing whether the adult’s behaviour constitutes a potentially chargeable criminal or regulatory offence, for example in relation to public nuisance, health hazard, or anti social behaviour, rather than the root cause of the behaviour - a mental disorder or disorders.
So, the matter of concern consists of this request - for guidance to be provided as to how to incorporate consideration of Executive Dysfunction into the assessment of mental capacity and how to assess when the point when external intervention can be triggered has been reached.
” Open source report
Concerns raised 1 Lack of available British Sign Language interpreters for Deaf patients with mental health difficulties View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Imogen Alice NUNN · 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
Imogen Alice NUNN was found deceased at her home on 1 January 2023 after leaving a party and being reported as a high-risk missing person; the circumstances text states that she had consumed a substance bought online. The principal concern was the lack of available British Sign Language interpreters for Deaf patients receiving mental health support, particularly for urgent assessments when patients were in crisis.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of available British Sign Language interpreters for Deaf patients with mental health difficulties
Wider context from the report “During the course of the Inquest (which has yet to be concluded) I heard evidence that there was a lack of availability of British Sign Language Interpreters able to help support Deaf patients in the community who were being treated with mental health difficulties . This was particularly apparent when mental health staff were seeking an interpreter at short notice for a patient who was in crisis . The lack of interpreters available has meant that urgent assessments are being carried out with no interpreters present .
The overall lack of British Sign Language Interpreters has also meant that this Inquest has itself had to be delayed/adjourned for two months due to there being no available Interpreters to interpreter for two deaf witnesses over the two week period of the Inquest.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual NHS Trusts and employers determine staffing levels and workforce composition, including appropriate weekend cover.
Verbatim wording from the response “Individual NHS Trusts and other employers are responsible for determining staffing levels and workforce composition. They are best placed to understand their services and the needs of their patients in order to deliver safe and effective care. I would expect South West London & St George’s Mental Health Trust, and all other NHS Trusts to ensure that their staffing arrangements, including weekend cover, are appropriate, following the tragic death of Ms Nunn.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS trusts and integrated care boards are responsible for making Equality Act reasonable adjustments to ensure accessible services.
Verbatim wording from the response “It is for individual NHS organisations including NHS trusts and integrated care boards to comply with the Equality Act 2010. Under the Equality Act 2010, organisations have a legal duty to make changes in their approach or provision to ensure that services are as accessible to people with disabilities as they are for everybody else. These changes are called reasonable adjustments. The Reasonable Adjustment Flag was developed in the NHS Spine” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commissioning community mental health services, including adequate BSL interpreter provision, is the responsibility of integrated care boards.
Verbatim wording from the response “You raised in your report concerns about the availability of British Sign Language (BSL) interpreters available in the local community. We fully recognise the importance of the provision of interpreters within community mental health services, both to support patients and to ensure that comprehensive mental health assessments take place in a timely manner. Commissioning of community mental health services is the responsibility of integrated care boards, and this includes responsibility for ensuring that there is adequate provision of British Sign Language interpreters to support deaf patients in the community.” 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.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations