24 Mar 2025 Thomas Alexander GLOVER · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 4 Failure to increase vigilance when patients with para-oesophageal hiatus hernia present with symptoms View source Lack of patient awareness of the increased risk of para-oesophageal hiatus hernia View source Lack of awareness among non-gastro specialist medical clinicians of para-oesophageal hiatus hernia and its additional risk View source Failure of NHS England online guidance to distinguish between hiatus hernia types View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Thomas Alexander GLOVER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas Glover died at Broomfield Hospital on 22 May 2024 after a delayed presentation of a strangulated hiatus hernia with an ischaemic stomach, followed by emergency surgery, multi-organ failure and end-of-life care. The report identified a missed opportunity for earlier diagnosis after his discharge from Ipswich Hospital, and raised concerns about limited awareness among NHS clinicians of the differing risks associated with para-oesophageal hiatus hernias and the lack of distinction in NHS England guidance.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to increase vigilance when patients with para-oesophageal hiatus hernia present with symptoms
Wider context from the report “4. As a result, the lack of understanding of the difference between the two types of hiatus hernia within the medical community means that there is no increased vigilance taken when individuals with a para-oesophageal hiatus hernia present with 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 Lack of patient awareness of the increased risk of para-oesophageal hiatus hernia
Wider context from the report “5. In addition, the cohort of individuals who suffer from para-oesophageal hiatus hernia in England, are unaware of the increased risk posed by their condition and are therefore unable to advocate for more testing, or seek a second opinion when worrying symptoms do arise .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 awareness among non-gastro specialist medical clinicians of para-oesophageal hiatus hernia and its additional risk
Wider context from the report “2. However, it was heard in evidence that in England many non-gastro specialist medical clinicians within the NHS are unaware of the difference in the two types of hiatus hernia , and are therefore unaware of the additional risk posed to the 5-15% of patients with a para-oesophageal hiatus hernia .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 NHS England online guidance to distinguish between hiatus hernia types
Wider context from the report “3. It was heard in evidence that the NHS England online guidance makes no distinction between the two types of hiatus hernias , whereas the guidance for NHS Scotland does.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clinical guidelines and clinician training are provided through NICE, Royal Colleges, employers, professional bodies and individual doctors’ CPD responsibilities.
Verbatim wording from the response “Clinical guidelines for healthcare professionals are published by institutions such as the National Institute for Health and Care Excellence (NICE) and the Royal Colleges. Each Royal College has a curriculum and training programme for clinicians.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS.UK and NHS England are not responsible for publishing clinical guidelines or providing clinical education to healthcare professionals.
Verbatim wording from the response “The NHS website does not publish clinical guidelines for use by healthcare professionals. NHS England is not commissioned to provide clinical education to healthcare professionals, which means the information on NHS.UK has not been designed for specialist clinical education or to raise awareness of conditions among the medical community.” 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 Symptoms and signs of acute bowel obstruction do not differ between rolling and sliding hiatus hernias, and treatment is generally the same.
Verbatim wording from the response “The NHS.UK website provides general advice for managing a hiatus hernia (https://www.nhs.uk/conditions/hiatus-hernia/), which includes lifestyle changes and, in some cases, medical treatments. Whilst rolling hiatus hernias are a specific type of hernia, the treatment approach is generally the same as for the more common sliding hiatus hernia.” 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 Existing NHS.UK guidance provides general hiatus hernia advice, red-flag warnings and directions to urgent assessment, sufficiently addressing public information needs.
Verbatim wording from the response “I have been advised by NHS England that the NHS website for England (NHS.UK) provides members of the public with clear and accurate health information to help them understand what, if any, next steps they need to take with regards to the management of their condition. The guidance on NHS.UK is simple and action-oriented and is designed to help members of the public understand their symptoms and make sure they seek the right help at the right time.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 20 Failure to grade fatal severe harm correctly View source Failure to examine the Trust's own clinical governance processes View source Unreliability of Trust safety and complaints data View source Failure to ensure midwives complete current mandatory training View source Failure of harm-only reporting to identify underlying safety problems View source Failure to notify external and internal patient-safety bodies of serious incidents View source Lack of a system of remedial training View source Inconsistent categorisation of harm for cooled babies with hypoxic injury View source Lack of document version control and audit View source Failure to learn from identified safety issues and themes View source Lack of a culture of candour View source Lack of assured ongoing funding for MSNI investigations View source Insufficiently skilled and trained clinical governance personnel View source Failure of clinical reporting to provide a holistic and complete account of evidence View source Failure to categorise a death-causing harm event correctly View source Inadequate Trust investigations failing to identify safety issues View source Failure to investigate senior staff roles in disputed safety-report decisions View source Failure to provide relevant information transparently and openly View source Chaotic clinical governance arrangements View source Untrained clinical governance staff View source See 17 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ida Jean Lock · 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
Ida Jean Lock died on 16 November 2019 after suffering a lack of oxygen during delivery on 9 November 2019, resulting in severe hypoxic-ischaemic brain damage. The report describes missed opportunities for enhanced care and obstetric input, delays in responding to fetal distress, and initially ineffective neonatal resuscitation. The principal concerns include the Trust’s alleged lack of candour and transparency, deficient clinical and maternity governance, inadequate investigations, gaps in mandatory and remedial training, and inappropriate grading of the harm suffered.
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 grade fatal severe harm correctly
Wider context from the report “14. The Trust graded Ida’s level of harm as “moderate”, even after her death . This grading should have been adjusted to "severe" by the Trust before Ida was transferred to Royal Preston Hospital as the consultant paediatrician identified that she had sustained a severe hypoxic ischaemic encephalopathy due to fetal bradycardia.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 examine the Trust's own clinical governance processes
Wider context from the report “7. As a result of the Trust's deficient processes, the Trust did not undertake any examination of its own clinical governance processes , which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust's clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements, defensive attitudes and inappropriate self-congratulation. The clinicians' reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unreliability of Trust safety and complaints data
Wider context from the report “5. Trust figures to the Board provided in 2025 stated that there were no complaints over 6 months old when the Trust at the time of the inquest have not responded to ████████ and ████████'s 1 June 2020 complaint., Together with the Trust's failure to categorise Ida's death as only "Moderate Harm" (see point 4 above) cause me also to have concern about the reliability of Trust's data .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure midwives complete current mandatory training
Wider context from the report “11. The Band 5 midwife supporting ████████ in Labour had not undertaken her required mandatory training and this fact had not been provided and was only revealed at the inquest as part of the evidence of the Head of Midwifery in March 2025. I was also concerned to learn that in 2025 non-completion of mandatory training was still an issue as ████████ had not completed her mandatory training.
12. It concerns me that the Trust do not have robust systems in place to ensure that any midwife who has not completed her mandatory training is subject to immediate action to ensure that all mandatory training is completed and is in date .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 harm-only reporting to identify underlying safety problems
Wider context from the report “15. The 2024 NHSE Learn from patient safety events (LFPSE) guidance that replaced the National Reporting and Learning System (NRLS) confirms that the recording and analysis of patient safety events that occur in healthcare support the NHS to improve learning from patient safety events to help make care safer. There is a significant risk that if reporting is graded on harm alone , clinical care that resulted in hypoxic brain damage during delivery and which was prevented by therapeutic cooling, will not adequately identify the problems that caused the harm during the delivery .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to notify external and internal patient-safety bodies of serious incidents
Wider context from the report “4. The Trust did not disclose that they had failed to notify the external bodies namely the CQC and the then CCG [ICB] via STEIS and the Trust's internal Serious Incidents Reporting Investigation panel , none of which was noted by the Trust's Patient Safety Summits .The matter was reported to the Coroner a year after Ida's death by the family after the Trust took no action to do so, despite being on notice of failures in treatment from the HSIB report Ida’s harm was at no point categorised by the Trust as a harm event that caused “death”.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a system of remedial training
Wider context from the report “13. There was no remedial training was put in place for either the midwives involved in Ida's delivery and resuscitation or for the paediatric SHO after Ida’s death. This raises a significant concern that the Trust do not operate a system of remedial training when this inquest has identified remedial training was required for ████████, ████████, ████████ and ████████
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistent categorisation of harm for cooled babies with hypoxic injury
Wider context from the report “16. ████████ confirmed that nationally there is inconsistency in categorisation of harm for babies who sustain a hypoxic injury due to fetal bradycardia in labour and who require cooling and clarification and guidance would assist prevent further maternity deaths and ensure full and proper investigation of hypoxic injuries sustained in labour.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 document version control and audit
Wider context from the report “7. As a result of the Trust's deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust's clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents , untrained staff, chaotic clinical governance arrangements, defensive attitudes and inappropriate self-congratulation. The clinicians' reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 learn from identified safety issues and themes
Wider context from the report “2. ████████s evidence to the inquest was that a deep-seated and endemic culture within the Trust leads to denial and a failure to learn . ████████'s Investigation report was published in 2015, the Trust is ten years on and still issues and themes identified in 2015 were very much in issue in 2019 and still exist at the Trust as identified by Ida’s inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 culture of candour
Wider context from the report “1. I am concerned that there is not a culture of candour within University Hospitals of Morecambe Bay NHS Foundation Trust (Trust) and the impact that this has on safety, learning and implementing required changes to prevent deaths. Urgent action is required by the Trust to meaningfully embed the Duty of Candour
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 assured ongoing funding for MSNI investigations
Wider context from the report “18. The MSNI is now hosted by the CQC with funding secured for the next two years but no certainty as to ongoing funding after this date . These independent investigations by specialist skilled investigators into the most serious of events is an essential safeguard to the lives of mothers and unborn children.
19. Without an assurance that funding will continue beyond 2027 I am concerned that significant harm events to mothers and babies and deaths such as Ida's will go unrecorded and lessons that should be learned to prevent future maternal and baby deaths will go unnoticed, and there will be a risk of future maternity 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 Insufficiently skilled and trained clinical governance personnel
Wider context from the report “6. I consider the clinical governance arrangements at the Trust require urgent review to ensure the appropriate personnel are in place, with the necessary training and skills to deliver robust clinical governance to ensure patient safety in maternity care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical reporting to provide a holistic and complete account of evidence
Wider context from the report “7. As a result of the Trust's deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust's clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements, defensive attitudes and inappropriate self-congratulation. The clinicians' reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence , did not provide relevant information until it was extracted from the witness in testimony , that resulted in rolling disclosure of documents and additional witness evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 categorise a death-causing harm event correctly
Wider context from the report “4. The Trust did not disclose that they had failed to notify the external bodies namely the CQC and the then CCG [ICB] via STEIS and the Trust's internal Serious Incidents Reporting Investigation panel, none of which was noted by the Trust's Patient Safety Summits .The matter was reported to the Coroner a year after Ida's death by the family after the Trust took no action to do so, despite being on notice of failures in treatment from the HSIB report Ida’s harm was at no point categorised by the Trust as a harm event that caused “death” .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Trust investigations failing to identify safety issues
Wider context from the report “9. All investigations conducted by the Trust to date in respect of Ida’s death have been unskilled, superficial, brief, failed to identify issues and left the family without answers and were all features identified by the 2015 Kirkup Report. In view of the continuing culture at the Trust, this cause a significant concern that issues of safety and safeguarding are not properly considered, transparently engaged with and then addressed formally in respect of a child fatality and serious injury by the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate senior staff roles in disputed safety-report decisions
Wider context from the report “8. ████████ is now Head of Compliance and Assurance at the Trust but that there has been no investigation into her role in respect of reneging on the Trust's acceptance of the HSIB report at senior management level and with the family as was indicated by her approval of the July 2021 position statement. Similarly, ████████ is now Head of Midwifery at the Trust and there has been no investigation in respect of her disputing the HSIB findings and submission of challenge to the HSIB report in Ida’s case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide relevant information transparently and openly
Wider context from the report “3. The Trust's approach to the inquest has been one of a lack of transparency and openness, failure to provide relevant information and a failure to identify with candour the defective clinical governance processes that have operated at the Trust from 2019 to present day.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Chaotic clinical governance arrangements
Wider context from the report “7. As a result of the Trust's deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust's clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements , defensive attitudes and inappropriate self-congratulation. The clinicians' reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Untrained clinical governance staff
Wider context from the report “7. As a result of the Trust's deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust's clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements , defensive attitudes and inappropriate self-congratulation. The clinicians' reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and update national guidance on recording patient safety events and levels of harm.
Verbatim wording from the response “To support the new system and framework, NHS England has published guidance on recording patient safety events and levels of harm (updated in October 2024) - NHS England » Policy guidance on recording patient safety events and levels of harm. For example, severe physical harm is defined as when at least one of the following apply:” Source location Joint response from DHSC and NHSE
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 Operate a regional procedure for escalating serious maternity patient-safety incidents to regional and national NHS England teams.
Verbatim wording from the response “NHS England North West (NW), has developed a Management of Patient Safety Incidents Standard Operating Procedure (April 2024), which ensures escalation of the maternity incidents of serious concern to the NW Regional Maternity Team. The ICB are responsible for escalating concerns, which are shared directly with the regional maternity team. The regional maternity team receive, monitor, and share escalation through the regional governance architecture. By extreme exception(s), the significant concerns are escalated to the National Chief Midwifery Officer and the National Obstetric Lead within NHS England.” Source location Joint response from DHSC and NHSE
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 Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share learning across regional and national NHS services.
Verbatim wording from the response “I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Ida, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.” Source location Joint response from DHSC and NHSE
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 University Hospitals Morecambe Bay NHS Foundation Trust and Lancashire and South Cumbria ICB will address specific changes arising from the report.
Verbatim wording from the response “My response therefore focuses on concern D and E. I note that you have also addressed this report to University Hospitals Morecambe Bay NHS Foundation Trust (UHMBT) and NHS Lancashire and South Cumbria Integrated Care Board (LSC ICB). These organisations will address specifics as to the changes being implemented as a result of the Report. NHS England’s response to you is also made on behalf of the Department of Health and Social Care (DHSC), and I understand that they will not therefore be issuing a separate response to the Coroner. With DHSC input, I have also addressed in this response some of your concerns regarding A and B.” Source location Joint response from DHSC and NHSE
Open published response
19 Mar 2025 Sheridan Tate Pickett · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of guidelines for communication and information sharing between private psychiatry providers and NHS services providing parallel neurodiversity care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sheridan Tate Pickett · 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 9 August 2024, Sheridan Tate Pickett sustained fatal injuries after falling from a height out of a window; the inquest concluded that the death was suicide. The concern was that information about an overdose and advice not to recommence ADHD medication was not shared with the private ADHD provider, and that there were no current guidelines governing information sharing between private psychiatry providers and NHS services involved in parallel 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 Lack of guidelines for communication and information sharing between private psychiatry providers and NHS services providing parallel neurodiversity care
Wider context from the report “1. The inquest heard evidence that Mr Pickett had a history of mental health issues and received an online diagnosis of ADHD from a private service provider (which prescribed Mr Pickett with medication too). Following his diagnosis Mr Pickett was admitted into an NHS hospital having taken an overdose. In their discharge letter the hospital suggested that the ADHD medication should not be recommenced. This information was not provided to the private ADHD provider which continued to prescribe Mr Pickett with ADHD medication.
I am concerned that there are no current guidelines governing communication and information sharing as between private psychiatry providers offering assessment, care and treatment in relation to neurodiversity and NHS services involved with providing care and treatment in parallel .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing hospital discharge guidance already governs information sharing between private and NHS providers, including medication and care information.
Verbatim wording from the response “In your report, you raise concerns that there are no current guidelines governing communication and information sharing between private providers and NHS providers. The following guidance, Hospital discharge and community support guidance - GOV.UK states that:” Source location Response from DHSC
Open published response
19 Mar 2025 Winnie Harrop · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of clear cross-sector guidance on when and in what circumstances patients may be returned to care homes View source Failure to ensure that discharge to a non-nursing care home is appropriate for a patient's condition and care needs View source Failure of discharge letters to communicate clinically significant sedation and oxygen requirements View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Winnie Harrop · 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
Winnie Harrop collapsed at a care centre on 12 August 2024, was treated in hospital after sustaining facial fractures, and was discharged back to the care centre with a new oxygen requirement but without oxygen. She became drowsy and unresponsive, was readmitted on 13 August, and died in hospital on 16 August 2024. The principal concerns were unclear health and social care guidance about discharge to a care home, discharge while overly sedated, and a discharge letter that did not record the sedation level or new oxygen requirement.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clear cross-sector guidance on when and in what circumstances patients may be returned to care homes
Wider context from the report “(1) There is no clear guidance between health and social care as to when and in what circumstances it is appropriate to send a patient back to a care home . Ms Harrop was discharged back to the care home less than 24 hours following her admission despite being overly sedated. The care home was not a nursing home. Ms Harrop’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that discharge to a non-nursing care home is appropriate for a patient's condition and care needs
Wider context from the report “(1) There is no clear guidance between health and social care as to when and in what circumstances it is appropriate to send a patient back to a care home. Ms Harrop was discharged back to the care home less than 24 hours following her admission despite being overly sedated . The care home was not a nursing home . Ms Harrop’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 discharge letters to communicate clinically significant sedation and oxygen requirements
Wider context from the report “(1) There is no clear guidance between health and social care as to when and in what circumstances it is appropriate to send a patient back to a care home. Ms Harrop was discharged back to the care home less than 24 hours following her admission despite being overly sedated. The care home was not a nursing home. Ms Harrop’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with NHS England to ensure local systems follow and embed existing hospital discharge guidance.
Verbatim wording from the response “Once again, I would like to offer my sincere condolences to Ms Harrop’s family. This situation is an unacceptable one, and I am truly sorry for the devastating and irreversible consequences this has had. I can assure you that my officials are working with colleagues in NHS England, to ensure this situation is avoided at all costs in the future, and that local systems follow and embed the existing guidance.” 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 Clear statutory guidance already covers hospital discharge and collaboration with onward care providers, contrary to the concern that guidance is lacking.
Verbatim wording from the response “Your report raises concerns over a lack of clear health and social care guidance on hospital discharge, specifically under what circumstances it is appropriate to send a patient back to a care home.” Source location Response from DHSC
Open published response
14 Mar 2025 Dominic Martin PHILIP · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 3 Unexplained exposure to Lidocaine, including for people allergic to Lidocaine View source Lack of pre-injection identification of potential allergy to iodinated contrast agents View source Failure to maintain accountable removal and stock counts for Lidocaine View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dominic Martin PHILIP · 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
Dominic Martin Philip died at Kettering General Hospital on 3 February 2023 from an anaphylactic reaction to contrast medium injected for an abdominal CT scan. Concerns included whether potential allergies to contrast medium could be identified before injection, the unexplained presence of Lidocaine in his blood despite his disclosed Lidocaine allergy, and controls over the storage and removal of Lidocaine.
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 Unexplained exposure to Lidocaine, including for people allergic to Lidocaine
Wider context from the report “b) Mr Philip did disclose an allergy to Lidocaine. The toxicology report records that Lidocaine was detected in Mr Philip’s blood post-mortem. Despite the hospital conducting a comprehensive review of the care provided, it has not been possible to ascertain why Lidocaine was present in Mr Philip’s system . Aside from the contrast medium, the only medication that Mr Philip received at hospital was IV Tazocin, IV paracetamol, Oramorph and IV saline. The toxicologist has also ruled out any possibility of contamination of the blood sample during testing. The toxicologist adds “I note that Mr Philip described as healthy so I would not expect its use outside a hospital setting”. There was no other source identified at inquest . I am therefore concerned that Mr Philip has come into contact with Lidocaine without any explanation – could there be a contaminated supply of medication? Have there been any similar unexplained occurrences anywhere else in the country? This is of course of particular concern to those who, like Mr Philip, are allergic to Lidocaine .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 pre-injection identification of potential allergy to iodinated contrast agents
Wider context from the report “a) It was stated in evidence that - an X-Ray is no longer preferred as it is not sensitive enough and a smaller obstruction might be missed; anaphylactic type reactions to iodinated contrast agents are rare accounting for 0.6% of cases with only 0.04% considered aggressive; and almost all contrast reactions that are life threatening occur within 20 minutes of intravenous injection. The current policy appears to be that a patient referred for a CT scan by the Emergency Department is to be accompanied by a doctor trained in advanced life support (ALS). In Mr Philip’s case, he was accompanied by a Core Trainee Year 2 who had ALS training. The policy for planned/outpatient interventions was not fully explored at inquest, but there was a suggestion that there might be some possibility testing for an allergic reaction to the contrast medium in advance of such an appointment? My concern is that if a patient has never before had contrast medium (as was the case with Mr Philip) they cannot possibly know if they have an allergy to it . Making arrangements for ALS after the event seems reactionary and I wondered if any other options might be available which would flag a potential allergy before the contrast is injected .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accountable removal and stock counts for Lidocaine
Wider context from the report “c) It has also been brought to my attention in a different case currently under investigation within my jurisdiction that as Lidocaine is a prescription only medication, it needs to be stored in a locked cupboard. However, Lidocaine is not a Controlled Drug which means that clinicians do not need a double signature to remove the medication from the stock and it is not subject to a count of the stock each time an ampoule is used . The Hospital has stated that “The use of Lidocaine will vary within each area dependant on the patients being seen within each department and treatments given. Stock levels are reviewed by pharmacy to ascertain stock required. Unless a large amount of stock was removed from a single clinical area there would be no alert to indicate that Lidocaine was being removed for reasons other than patient treatment ”.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Other agencies, particularly the Trust, are responsible for directly addressing the concerns about medicine handling and related safety controls.
Verbatim wording from the response “Having reviewed these concerns, it is my view that the other agencies with which you have shared the report are best placed to respond directly to the issues you have raised, which are relevant to their respective areas. We did however contact NHS England, and I have shared below the organisation’s comments.” Source location Response from Department for Health and Social Care
Open published response
13 Mar 2025 Mr Paul Timothy Dunne · Prevention of Future Deaths report South London
View report summary
Concerns raised 12 Failure of Mental Health Trust leadership to recognise serious professional knowledge and judgment deficits View source Failure to direct staff to the need for 1:1 monitoring View source Failure to apply A&E risk assessment and staffing policies to mental health staff View source Absence of audit of absconsions and mental health liaison in A&E View source Failure to recognise high-risk mental health patients View source Incorrect understanding of Mental Health Act assessment criteria View source Failure to acknowledge communicated patient risk View source Failure to complete required duplicate A&E clinical record entries by mental health staff View source Lack of shared access to mental health and A&E clinical records View source Failure to document mental health assessments when no recording location is available View source Inconsistent risk assessment documentation and training across departments View source Gaps in mental health professionals’ knowledge and clinical judgment View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Paul Timothy Dunne · 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 Paul Dunne was brought to A&E after a paracetamol overdose and was considered at high risk of suicide, but did not receive continuous 1:1 observation. He absconded several times and was found dead after suspending himself in a nearby children's playground. Concerns included failures in risk assessment, observation, communication, documentation and escalation, as well as separate clinical-record systems used by mental health and A&E staff.
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 Mental Health Trust leadership to recognise serious professional knowledge and judgment deficits
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 direct staff to the need for 1:1 monitoring
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need . When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to apply A&E risk assessment and staffing policies to mental health staff
Wider context from the report “2. The Mental Health Trust
• Staff and it appears the director even at the time of the inquest did not appreciate that the A&E policies (Missing Persons, Shared Care) which required risk assessment after an absconsion and alerting managers to the need for extra temporary staff if 1:1 monitoring was needed, also applied to MH staff.
• Evidence was heard that staff in KCH A&E and Oxleas NH Trust had been trained on different risk assessment documents. Although meetings had been reinstated between departments, there had been no audit of absconsions or MH liaison in A&E.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 audit of absconsions and mental health liaison in A&E
Wider context from the report “2. The Mental Health Trust
• Staff and it appears the director even at the time of the inquest did not appreciate that the A&E policies (Missing Persons, Shared Care) which required risk assessment after an absconsion and alerting managers to the need for extra temporary staff if 1:1 monitoring was needed, also applied to MH staff.
• Evidence was heard that staff in KCH A&E and Oxleas NH Trust had been trained on different risk assessment documents. Although meetings had been reinstated between departments, there had been no audit of absconsions or MH liaison in A&E.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 high-risk mental health patients
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk , despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Incorrect understanding of Mental Health Act assessment criteria
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to acknowledge communicated patient risk
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to complete required duplicate A&E clinical record entries by mental health staff
Wider context from the report “3. MH staff and A&E staff write their clinical records in different systems and hospital staff do not have access to MH Rio records. MH staff attending A&E departments are asked to make a double entry in the A&E records as well. Here that was omitted, potentially with fatal risks. Moving to a combined electronic system (now identified as EPIC) has long been the aim of the local health providers, but evidence was heard that the pace of introduction, which is very slow, is in the hands of national NHS leadership.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 shared access to mental health and A&E clinical records
Wider context from the report “3. MH staff and A&E staff write their clinical records in different systems and hospital staff do not have access to MH Rio records . MH staff attending A&E departments are asked to make a double entry in the A&E records as well. Here that was omitted, potentially with fatal risks. Moving to a combined electronic system (now identified as EPIC) has long been the aim of the local health providers, but evidence was heard that the pace of introduction, which is very slow, is in the hands of national NHS leadership.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to document mental health assessments when no recording location is available
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment , as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistent risk assessment documentation and training across departments
Wider context from the report “2. The Mental Health Trust
• Staff and it appears the director even at the time of the inquest did not appreciate that the A&E policies (Missing Persons, Shared Care) which required risk assessment after an absconsion and alerting managers to the need for extra temporary staff if 1:1 monitoring was needed, also applied to MH staff.
• Evidence was heard that staff in KCH A&E and Oxleas NH Trust had been trained on different risk assessment documents. Although meetings had been reinstated between departments, there had been no audit of absconsions or MH liaison in A&E.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Gaps in mental health professionals’ knowledge and clinical judgment
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” Open source report
Concerns raised 2 Delays in patient handovers at Royal Cornwall Hospital View source Failure to share information about ambulance delays between police and ambulance services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lachlan Charles Campbell · 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
Lachlan Charles Campbell was found unconscious outside a railway station after taking drugs and died in hospital on 1 November 2022 following hypothermia, bronchopneumonia and combined drug intoxication. The report identifies concerns about delayed ambulance attendance, delays in hospital handovers, inadequate care by responding police officers, and information sharing between police and ambulance services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in patient handovers at Royal Cornwall Hospital
Wider context from the report “1) Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital
Mr Campbell had a history of recreational drug misuse with previous non-intentional overdoses. On 31/10/22, he travelled by train from St Austell to St Erth to visit a friend. While with his friend, it is understood he took drugs as he then became unconscious/fell asleep.
His friend took him back to the railway station to catch the last train back to St Austall.
At approximately 00:15 on 1/11/22, a bus driver saw Lachlan outside the train station. He was on his knees, bent forwards with his head on the ground in what was described as a ‘prayer position.’
A concern for welfare call was made to the emergency services. A police response was delayed, understandably, owing to a higher priority call being received in relation to an incident of potential domestic violence to which the Officers were diverted.
The Officers arrived with Lachlan shortly after 01:00. At 01:42, a request was made for an ambulance. This resulted in a Category 2 disposal requiring an attendance within an average of 18 minutes with 90% of incidents to be attended upon within 40 minutes.
The Officers left Lachlan at the scene under the understanding that an ambulance would arrive shortly. They had initially wondered if Lachlan was the male involved in the incident of Domestic Violence but once it was recognised he was not and that the suspect was still at large, there was a concern to apprehend the suspect to safeguard the female victim.
After a downpour, Officers returned to the scene shortly before 05:00 to find Lachlan in much the same position but now soaked through. They discussed their options and the risk of hypothermia. A chasing call was made to the ambulance service and it was identified there were still 13 Category 2 or higher cases ahead of them. No ETA was provided.
The Officers decided to watch Lachlan from their car. At approximately 06:00, his breathing became agonal. The outstanding call was upgraded to Category 1. An ambulance crew arrived on scene at 06:15 just over 4.5 hours after the first call against a target time of 18 minutes. The situation could not be retrieved and resuscitation efforts were abandoned as futile at 07:45. An expert, Professor Lyon, opined that had Lachlan been conveyed to hospital in a timely manner, his death would have been avoided.
At inquest, the jury heard from ████████ who works in the patient safety team at South West Ambulance Service Trust. She told us: On 31 October 2022, there were over 730 hours of ambulance time lost to handovers that were over the 15 minute target at RCHT, Derriford Hospital and North Devon District Hospital (NDDH). This is equivalent to approximately 60 DCA ambulance shifts lost to delays (based on a standard 11 hour shift). At RCHT, the average handover time per patient was one hour, 55 minutes and 57 seconds. At Derriford, the average handover was seven hours, five minutes and four seconds. At NDDH, the average handover was two hours, 12 minutes and 27 seconds.
These events happened some time ago and I wanted to know if the situation had improved in the meantime. I was advised that in January 2025, the average handover time per patient at Royal Cornwall Hospital was just under 2 hours 15 minutes, in other words, the situation has worsened. This gives rise to an obvious concern and it is in these circumstances that I write to you.
May I also take the opportunity to bring to your attention that I have written Preventing Future Death (PFD) reports with the same concerns to two previous Ministers. I am aware some of my colleagues have additionally written with the same concerns.
Included in the Reply to my first PFD was a response from ████████, the Chief Executive of the local ICB (to whom this is copied) which set out, most helpfully, a plan of action over the coming years to relieve the current pressures. It is entirely a matter for you how you choose to reply to this report but you may feel an update from Ms Shields would be informative.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to share information about ambulance delays between police and ambulance services
Wider context from the report “2) Information Sharing
There is a concern also about how information was shared between the police and ambulance service. Both police officers said that, had they been aware of the extent of ambulance delays, they may have considered other options , notably, conveying Lachlan to hospital in a police car.
I am writing separately to SWAST and Devon & Cornwall Police in this regard and you do not need to address this concern.
” 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 Set out lessons learned from winter urgent and emergency care pressures.
Verbatim wording from the response “In addition, later in the Spring we will also 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 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 2025 NHS mandate 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 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 Put improvements in place to further improve urgent and emergency care services during 2025/26.
Verbatim wording from the response “In addition, later in the Spring we will also 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 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 South Western Ambulance Service NHS Foundation Trust is responsible for addressing information-sharing concerns raised in the report.
Verbatim wording from the response “The report raises concerns over emergency service pressures, including ambulance response times and handover delays, and information sharing between police and ambulance emergency services. I recognise the concerns raised with health and care delivery in the region, which align with representations from local members of parliament.
In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. I understand that the South Western Ambulance Service NHS Foundation Trust is also writing to you separately to address the matters of concern you have raised for them which include the issues with information sharing.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 10 Failure to clearly explain and differentiate the Physician Associate role from medically qualified practitioners View source Lack of updated guidelines for rapid sequence induction of anaesthesia in emergency surgery View source Inadequate medical supervision of Physician Associates managing undifferentiated Emergency Department patients View source Unavailability of promptly accessible suction for aspiration during rapid sequence induction View source Failure to inform patients and families that Physician Associates are not medically qualified View source Lack of public understanding of the Physician Associate role View source Lack of guidance on TIVA dosing and timing for rapid sequence induction View source Lack of updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction View source Failure to prevent Physician Associates undertaking roles outside their competency View source Lack of regulated scope-of-practice guidance and recognised training for Physician Associates View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Pamela Anne Marking · 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
Pamela Anne Marking was admitted with abdominal symptoms, was diagnosed with a nosebleed by a Physician Associate and discharged without medical review or direct medical supervision. She later returned with small bowel obstruction caused by an incarcerated femoral hernia and aspirated feculent fluid during induction of anaesthesia for emergency surgery, subsequently dying from respiratory failure and sepsis. The concerns included the Physician Associate’s role, supervision and scope of practice, and the absence of updated guidance for rapid sequence induction, TIVA and airway protection.
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 clearly explain and differentiate the Physician Associate role from medically qualified practitioners
Wider context from the report “1. The term ‘Physician Associate’ is misleading to the public
Mrs Marking’s son was under the mistaken belief that the Physician Associate was a doctor by this title in circumstances where no steps were taken by the Emergency Department or the Physician Associate to explain or clearly differentiate their role from that of medically qualified practitioners .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 updated guidelines for rapid sequence induction of anaesthesia in emergency surgery
Wider context from the report “6. Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery
Mrs Marking required a rapid sequence induction to protect her airway from aspiration of bowel contents as a consequence of small bowel obstruction. The consultant anaesthetist gave evidence that the ‘traditional’ use of consecutive syringes of induction agent and muscle relaxant was obsolete, and it was common practice locally and nationally to routinely undertake a RSI with Total Intravenous Anaesthesia, in the absence of updated local or national guidelines to support this practice .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 medical supervision of Physician Associates managing undifferentiated Emergency Department patients
Wider context from the report “5. Lack of guidelines for direct supervision and consideration of an appropriate level of autonomy for Physician Associates
Whilst there were discussions with the ‘supervising’ consultant the Physician Associate was effectively acting independently in the diagnosis, treatment, management and discharge of Mrs Marking without independent oversight by a medical practitioner . This gives rise to a concern that inadequate supervision or excessive delegation of undifferentiated patients in the Emergency Department to Physician Associates compromises patient safety.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 promptly accessible suction for aspiration during rapid sequence induction
Wider context from the report “8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic
Evidence was heard that cricoid pressure was ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 inform patients and families that Physician Associates are not medically qualified
Wider context from the report “3. The right of patients and family to seek a second opinion
The lack of public knowledge that a Physician Associate is not medically qualified has the potential to hinder requests by patients and their relatives who would wish to seek an opinion from a medical practitioner. It also raises issues of informed consent and protection of patient rights if the public are not aware or have not been properly informed that they are being treated by a Physician Associate rather than a medically qualified doctor.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 public understanding of the Physician Associate role
Wider context from the report “2. Lack of public understanding of the role of Physician Associate
Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 on TIVA dosing and timing for rapid sequence induction
Wider context from the report “7. Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI
Other than empirically increasing the rate of infusion of TIVA agents (Propofol and Remifentanil) no evidence was forthcoming as to the target range required to ensure and confirm an adequate depth of anaesthesia for patients or the length of time required prior to and following the administration of a muscle relaxant (Rocuronium) to facilitate intubation. This is despite TIVA being known to provide a slower onset of anaesthesia and approximately 50% of all anaesthetic related deaths are due to aspiration (NAP 4).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction
Wider context from the report “8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic
Evidence was heard that cricoid pressure was ineffective it was not routinely applied for a RSI intubation . After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent Physician Associates undertaking roles outside their competency
Wider context from the report “2. Lack of public understanding of the role of Physician Associate
Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 regulated scope-of-practice guidance and recognised training for Physician Associates
Wider context from the report “4. Lack of national and local guidelines and regulation of the scope of practice for a Physician Associate
A diagnosis of epistaxis was made by the Physician Associate without appreciating the relevance of the vomiting and lower abdominal discomfort and in the absence of understanding the need to undertake palpation of the groins in an abdominal examination in a patient who was unable to give a proper clinical history because of short term memory loss. No evidence was presented that the management of Mrs Marking was subject to a reflective practice review. Given their limited training and in the absence of any national or local recognised hospital training for Physician Associates once appointed , this gives rise to a concern they are working outside of their capabilities .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission an independent review of Physician Associate and Anaesthesia Associate roles and their contribution to multidisciplinary healthcare teams.
Verbatim wording from the response “This Government takes concerns about patient safety seriously. This is why, in November 2024, we commissioned ████████ to lead an independent review into PAs and AAs: Independent Review of the Physician Associate and Anaesthesia Associate - Hansard - UK Parliament. Whilst there are governance processes already in place for the Physician Associate (PA) and Anaesthesia Associate (AA) professions, the review will consider the safety of the roles and their contribution to multidisciplinary healthcare teams. The review will draw upon a range of national and international evidence to produce a comprehensive picture of the physician associate and anaesthesia associate roles. This will include published research, real world data, and patient and professional views.” 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 GMC regulation and existing NHS guidance already govern PA regulation, competence, scope, supervision and employer clinical governance.
Verbatim wording from the response “Regulation of PAs and AAs by the General Medical Council (GMC) began in December 2024. The GMC expects the vast majority of practising PAs and AAs to join the register within the first six months of regulation, and they will be required to do so within two years of regulation commencing. PAs and AAs who are registered with the General Medical Council (GMC) are required to follow the professional standards and behaviour set out in Good medical practice. This includes introducing themselves and their role in patient care.” 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 Existing NICE and GMC standards require healthcare professionals to identify their role to patients, addressing role-identification concerns.
Verbatim wording from the response “You highlight the limited awareness and understanding of the PA role and that the title is misleading. We are clear that an important part of being a healthcare professional is ensuring that the people they come into contact with understand who they are. All healthcare professionals should follow the National Institute for Health and Care Excellence (NICE) guidelines which state that healthcare professionals directly involved in a patient's care should introduce themselves and explain to their role to the patient.” 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 Medical Royal Colleges and professional bodies are considered best placed to respond on national anaesthesia guidelines.
Verbatim wording from the response “In preparing this response, the Department notes that the report has been sent to a number of medical Royal Colleges and professional bodies relating to anaesthesia. We think these organisations are best placed to respond to points 6, 7 and 8 of your report which” Source location Response from DHSC
Open published response
Concerns raised 2 Lack of clinical staff awareness of Clozapine's potential fatal side effects View source Inappropriate use of community treatment orders where sufficient evidence supports retention on a Mental Health Act section View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Luke Alexander Worrell · 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 Luke Alexander Worrell, who had treatment-resistant schizophrenia and was taking Clozapine, developed persistent vomiting, dehydration and an ileus before suffering a ruptured oesophagus and dying in hospital on 2 January 2021. The report identified concerns about clinical staff failing to recognise the potentially fatal gastrointestinal side effects of Clozapine and about the inappropriate use of a community treatment order instead of continued detention under a mental health section. The inquest narrative also described failures to recognise the need for face-to-face psychiatric assessment after his deterioration following discharge.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical staff awareness of Clozapine's potential fatal side effects
Wider context from the report “1. The lack of awareness by a series of clinical staff of the potential fatal side effects of Clozapine
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inappropriate use of community treatment orders where sufficient evidence supports retention on a Mental Health Act section
Wider context from the report “2. Inappropriate use of community treatment order , when there was sufficient evidence to keep on a MHA section .
” 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 Introduce additional professional oversight of decisions to make, vary, suspend, recall, revoke and discharge patients from Community Treatment Orders.
Verbatim wording from the response “Through the Mental Health Bill, which is currently making its way through Parliament, we are introducing further professional oversight in decisions regarding the use and operation of CTOs. The community clinician (the approved clinician who is responsible for overseeing the patient’s care as a community patient) will be involved in decision making in addition to the hospital-based responsible clinician. This includes the decision to make a person subject to a CTO, to vary or suspend conditions made under a CTO, to recall to hospital a patient subject to a CTO, to revoke a CTO after a patient has been recalled, and to discharge the patient from the CTO. This will help ensure better join up between inpatient and community clinical teams and make sure that patients subject to a CTO are benefiting from the framework they provide.” 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 Existing Mental Health Act guidance and recall powers provide clinicians with sufficient arrangements to manage CTO patients and determine appropriate care.
Verbatim wording from the response “CTOs are a form of supervised community treatment where an individual can be quickly recalled to hospital to be detained and treated. CTOs are intended to maintain ongoing contact with mental health services to provide support and help prevent relapse. In certain circumstances, patients subject to a CTO may be recalled to hospital under the Mental Health Act. Under section 17E of the Act, a patient can be recalled to hospital if they require medical treatment in hospital for their mental disorder and there would be a risk of harm to the health or safety of the patient or to other persons if the patient were not recalled to hospital for that purpose.” Source location Response from DHSC
Open published response
19 Feb 2025 Kenneth James CLAYTON · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 8 Insufficient availability of ward beds for Emergency Department patient flow View source Prolonged waits in Emergency Departments for ward beds View source Emergency Department design unsuitable for prolonged observation of high-risk patients View source Delays in discharging medically ready patients awaiting care packages or care home places View source Unavailability of height-adjustable hospital beds for patients cared for on Emergency Department trolleys View source Recurring prolonged waits in Emergency Departments for ward beds View source Inconsistent falls risk management in Emergency Departments View source Lack of nationally consistent falls risk management arrangements in Emergency Departments 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
Kenneth James CLAYTON · 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 James Clayton was admitted to Tameside General Hospital after falls at home and later had an unobserved fall in the Emergency Department while waiting about eight hours for an inpatient bed. He fractured his neck of femur, underwent surgery, deteriorated with complications, and died at the hospital. The concerns included prolonged Emergency Department waits, an environment and equipment that were not suited to prolonged observation of high-risk patients, limited bed availability linked to delayed discharges, and uncertainty about consistent national falls-risk management.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of ward beds for Emergency Department patient flow
Wider context from the report “3. The inquest was told that the primary reason for the challenges in moving patients through the Emergency Department was availability of beds . The evidence given was that the main challenge in freeing up beds was delayed discharge of patients who were medically ready for discharge but who needed a care package or a care home place to facilitate a safe discharge.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Prolonged waits in Emergency Departments for ward beds
Wider context from the report “1. The inquest heard evidence that a key factor in the fall was the prolonged time Mr Clayton was in the Emergency Department waiting for a bed to become available on a ward . The evidence was that he had been in the emergency department for about 8 hours when he fell. The inquest was told that the design of an Emergency Department is not suited to a need for prolonged observation of high risk patients. In addition generally patients are cared for on hospital trolleys which cannot be lowered in the way a hospital bed can be which further increases the risk of falls.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Emergency Department design unsuitable for prolonged observation of high-risk patients
Wider context from the report “1. The inquest heard evidence that a key factor in the fall was the prolonged time Mr Clayton was in the Emergency Department waiting for a bed to become available on a ward. The evidence was that he had been in the emergency department for about 8 hours when he fell. The inquest was told that the design of an Emergency Department is not suited to a need for prolonged observation of high risk patients . In addition generally patients are cared for on hospital trolleys which cannot be lowered in the way a hospital bed can be which further increases the risk of falls.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 discharging medically ready patients awaiting care packages or care home places
Wider context from the report “3. The inquest was told that the primary reason for the challenges in moving patients through the Emergency Department was availability of beds. The evidence given was that the main challenge in freeing up beds was delayed discharge of patients who were medically ready for discharge but who needed a care package or a care home place to facilitate a safe discharge .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 height-adjustable hospital beds for patients cared for on Emergency Department trolleys
Wider context from the report “1. The inquest heard evidence that a key factor in the fall was the prolonged time Mr Clayton was in the Emergency Department waiting for a bed to become available on a ward. The evidence was that he had been in the emergency department for about 8 hours when he fell. The inquest was told that the design of an Emergency Department is not suited to a need for prolonged observation of high risk patients. In addition generally patients are cared for on hospital trolleys which cannot be lowered in the way a hospital bed can be which further increases the risk of falls .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Recurring prolonged waits in Emergency Departments for ward beds
Wider context from the report “2. Prolonged waits in Emergency Department were on the evidence given to the inquest not unusual . As an example the court was told that on the morning the inquest was heard there were patients who had been waiting 40 hours for a bed on a ward .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistent falls risk management in Emergency Departments
Wider context from the report “4. The inquest was told that for patient safety it was important, that whilst there were delays in ED throughput of patients, that a robust falls risk management system was in place . Tameside Hospital had put additional measures in place to manage falls risk in ED in a more consistent way but it was unclear what steps were in place nationally to manage falls risk in a consistent way in Emergency Departments.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 nationally consistent falls risk management arrangements in Emergency Departments
Wider context from the report “4. The inquest was told that for patient safety it was important, that whilst there were delays in ED throughput of patients, that a robust falls risk management system was in place. Tameside Hospital had put additional measures in place to manage falls risk in ED in a more consistent way but it was unclear what steps were in place nationally to manage falls risk in a consistent way in Emergency Departments .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the 2025 NHS mandate and planning guidance containing urgent-care delivery priorities and implementation targets.
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. On the same day NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems. The planning guidance included an implementation target for improving A&E waiting times compared to 2024/25, with a minimum of 78% of patients seen within 4 hours in March 2026.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue improving urgent and emergency care services to improve access and restore constitutional waiting-time performance.
Verbatim wording from the response “The Government is clear that patients should receive the highest standard of service and care from the NHS. We acknowledge that urgent and emergency care performance has failed to deliver that standard in recent years. We have been honest about the challenges facing the NHS and we are serious about tackling the issues; however, we must be clear that there are no quick fixes. I would like to assure you we are committed to continuing to improve services to ensure patients can access the right care first time, only visiting A&E when necessary, and returning waiting times to the NHS constitutional standard where at least 95% of patients in A&E will be admitted, transferred or discharged within 4 hours.” Source location Response from DHSC
Open published response
Concerns raised 2 Insufficient ambulance service availability or resources for timely patient attendance View source Delays in ambulance crew release following hospital attendance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Diana FAIRWEATHER-PURKIS · 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
Diana Fairweather-Purkis waited 9 hours and 56 minutes for an ambulance after calling the 111 Service, was admitted to hospital, and died on 3 October 2022 due to multi-organ failure secondary to urosepsis. The report identifies insufficient ambulance availability, delays in releasing ambulance crews after hospital attendance because of patient handover delays, and delays in prescribing and administering antibiotics as substantive concerns or contributing factors.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient ambulance service availability or resources for timely patient attendance
Wider context from the report “1. There is insufficient Ambulance Service availability/resource to enable Ambulances to attend to patients in a timely manner and in accordance with relevant target attendance times .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 crew release following hospital attendance
Wider context from the report “2. There are excessive delays in Ambulance crews being released following attendance at hospital , due to delays in patients being handed over to hospital staff .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the 2025 mandate to NHS England prioritising improved 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. On the same day NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish NHS planning guidance requiring action to improve Category 2 ambulance response times and reduce avoidable dispatches, conveyances and handover delays.
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. On the same day NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish lessons learned from winter urgent and emergency care pressures.
Verbatim wording from the response “In addition, by this Spring we will also 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 improve services ahead of next winter.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Put in place improvements to urgent and emergency care services ahead of the next winter.
Verbatim wording from the response “In addition, by this Spring we will also 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 improve services ahead of next winter.” Source location Response from DHSC
Open published response
Concerns raised 6 Failure to establish fitness for surgery before operating View source Failure to ensure informed consent about surgical risks and mortality rates View source Inadequate follow-up after serious surgery abroad View source Lack of accessible return pathways to the operating hospital for post-operative complications View source Insufficient time for patients to consider additional surgery before consenting View source Unavailability of medical records for surgery and post-operative care 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
Anne TOWLSON · 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
Anne Towlson was found dead at home on 17 May 2024 after travelling to Turkey for planned tummy tuck and liposuction surgery, and additionally undergoing arm tuck surgery. Her arm wounds had not healed, with open, swollen and weeping wounds noted after her return to the UK; the cause of death was recorded as unascertained. Concerns included the lack of information about the Turkish hospital’s assessment, surgery and postoperative care, uncertainty about whether surgical risks were explained, the consenting process for the additional arm surgery, and limited follow-up after returning to the UK.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to establish fitness for surgery before operating
Wider context from the report “1) I am concerned about the fact that the inquest was unable to secure any information from the Turkish Hospital. We have no information about whether any independent enquiries were made either by the company who organised Mrs Towlson’s trip to Turkey for surgery, or the Turkish Hospital itself as to whether Mrs Towlson was fit for surgery. We have not been able to secure her medical records so have no understanding of what exactly the surgery consisted of, or what post-operative care and treatment was provided to Mrs Towlson.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 informed consent about surgical risks and mortality rates
Wider context from the report “2) I am concerned about the fact that we have no evidence to confirm whether Mrs Towlson was made aware of the risks and mortality rates associated with any of the surgical procedures she underwent in Turkey .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 follow-up after serious surgery abroad
Wider context from the report “4) Whilst I appreciate the UK Government has no control over what happens abroad, I am concerned about the fact that British Citizens are travelling abroad for significant and serious surgical operations with seemingly little in the way of follow up and no way to return easily to the operating Hospital if they encounter complications once they are back in the UK. This is not only dangerous but could place a significant burden on the NHS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of accessible return pathways to the operating hospital for post-operative complications
Wider context from the report “4) Whilst I appreciate the UK Government has no control over what happens abroad, I am concerned about the fact that British Citizens are travelling abroad for significant and serious surgical operations with seemingly little in the way of follow up and no way to return easily to the operating Hospital if they encounter complications once they are back in the UK . This is not only dangerous but could place a significant burden on the NHS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient time for patients to consider additional surgery before consenting
Wider context from the report “3) I am concerned about the fact that Mrs Towlson had travelled to Turkey to have a tummy tuck and liposuction but was offered additional arm tuck surgery when she arrived at the hospital. I have concerns about the consenting process for this additional surgery as, on the balance of probabilities, Mrs Towlson was not given enough time to properly consider this decision .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 medical records for surgery and post-operative care
Wider context from the report “1) I am concerned about the fact that the inquest was unable to secure any information from the Turkish Hospital. We have no information about whether any independent enquiries were made either by the company who organised Mrs Towlson’s trip to Turkey for surgery, or the Turkish Hospital itself as to whether Mrs Towlson was fit for surgery. We have not been able to secure her medical records so have no understanding of what exactly the surgery consisted of, or what post-operative care and treatment was provided to Mrs Towlson.
” 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 Consider how to communicate risks to people considering medical treatment abroad.
Verbatim wording from the response “We are considering the impact medical tourism is having regarding patient safety and are engaging with the Turkish Government to improve the patient pathway. The UK Government is also considering how we can most effectively communicate with those considering medical treatment abroad, to ensure people are better informed about the risks of surgery and help them to plan accordingly. To protect patient safety, we understand the need to ensure appropriate aftercare, including considering when it may be safe to travel home.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage with the Turkish Government to improve the patient pathway.
Verbatim wording from the response “We are considering the impact medical tourism is having regarding patient safety and are engaging with the Turkish Government to improve the patient pathway. The UK Government is also considering how we can most effectively communicate with those considering medical treatment abroad, to ensure people are better informed about the risks of surgery and help them to plan accordingly. To protect patient safety, we understand the need to ensure appropriate aftercare, including considering when it may be safe to travel home.” Source location Response from DHSC
Open published response
7 Feb 2025 Ella Louise Murray · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 6 Failure to take urgent safeguarding steps to remove children from an unsafe family home View source Delays in convening multi-agency safeguarding meetings View source Lack of shared access to safeguarding records across agencies View source Inadequate assessment of risk to children presenting with safeguarding and mental health concerns View source Failure to provide agencies with access to all relevant cross-sector safeguarding information View source Lack of a mechanism to convene urgent multi-agency safeguarding meetings 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
Ella Louise Murray · 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
Ella Louise Murray was 13 years old when she died at Kings College hospital on 15 November 2023 following an episode of hanging, after a period of self-harm, suicidal ideation and deteriorating mental health. The report raised concerns about the adequacy of her risk assessment and the failure to take urgent protective action, including removing her from home or convening an urgent multi-agency response. It also identified the lack of shared information and records across health, social care and education services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to take urgent safeguarding steps to remove children from an unsafe family home
Wider context from the report “(1)During the course of the inquest it became clear that Ella was a child in a complex family situation and showing signs of deterioration of her mental health. Her school had raised concerns about her with social services and taken steps to make sure she was seen by healthcare professionals when she indicated to staff at school she wanted to end her life on 13 November 2023. She was assessed by mental health nursing staff and accepted to the caseload of the Intensive Home Treatment Team. She was seen the following day and told the staff nurse who saw her that she was frightened of her stepfather and had run away from home barefoot and police called but she was brought back home by her mother who “grabbed her face” the morning she was seen. She told the nurse that she did not want to be in the family home and would rather go to prison and would harm herself or others is she had to stay at home.
(2) This disclosure led to the nurse making a Safeguarding Referral but this was made after she left Ella’s home and no urgent steps were taken to remove Ella either to a hospital bed or to ask social services to consider if she should be removed from the family home . Her school had raised concerns about her and she herself had indicated she wished to end her life. Evidence heard at the inquest was that this was the procedure in place and there is no shared access to records for all agencies and no way to convene an urgent multi-agency meeting to determine if Ella was safe to remain at home. Had steps been taken to share information between her school, social services and the mental health providers when she attend the emergency department on 13 November 2023 or early the following day rather than leave her at home she may have been removed from her home and may still be alive today.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 convening multi-agency safeguarding meetings
Wider context from the report “(3) Whilst there were concerns about the level of risk assessment undertaken on 14 November 2023 senior staff at the Trust gave evidence that she did not meet the criteria for admission to a hospital bed. This was difficult to reconcile with the documentary evidence as she was clearly crying out for help and her school had recognised this. No one agency involved had access to all the relevant information and concerns about Ella across the health, social care and education arenas. Evidence given suggested that shared records would assist but the ability to respond to urgent concerns would require a system change.
(4)It was brought to the court’s attention that the new Children’s Wellbeing and Schools bill includes a duty to share information to promote safeguarding. In addition the local authority may convene a strategy meeting under s47 of the Children Act 1989 although the speed of convening a meeting would depend on availability and would obviously not be as swift as for example attending an accident and emergency department . If a multiagency meeting had been convened this may have prevented Ella’s death and such action may reduce the risk of death for other children being in a similar 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 shared access to safeguarding records across agencies
Wider context from the report “(1)During the course of the inquest it became clear that Ella was a child in a complex family situation and showing signs of deterioration of her mental health. Her school had raised concerns about her with social services and taken steps to make sure she was seen by healthcare professionals when she indicated to staff at school she wanted to end her life on 13 November 2023. She was assessed by mental health nursing staff and accepted to the caseload of the Intensive Home Treatment Team. She was seen the following day and told the staff nurse who saw her that she was frightened of her stepfather and had run away from home barefoot and police called but she was brought back home by her mother who “grabbed her face” the morning she was seen. She told the nurse that she did not want to be in the family home and would rather go to prison and would harm herself or others is she had to stay at home.
(2) This disclosure led to the nurse making a Safeguarding Referral but this was made after she left Ella’s home and no urgent steps were taken to remove Ella either to a hospital bed or to ask social services to consider if she should be removed from the family home. Her school had raised concerns about her and she herself had indicated she wished to end her life. Evidence heard at the inquest was that this was the procedure in place and there is no shared access to records for all agencies and no way to convene an urgent multi-agency meeting to determine if Ella was safe to remain at home. Had steps been taken to share information between her school, social services and the mental health providers when she attend the emergency department on 13 November 2023 or early the following day rather than leave her at home she may have been removed from her home and may still be alive today.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 assessment of risk to children presenting with safeguarding and mental health concerns
Wider context from the report “(3) Whilst there were concerns about the level of risk assessment undertaken on 14 November 2023 senior staff at the Trust gave evidence that she did not meet the criteria for admission to a hospital bed. This was difficult to reconcile with the documentary evidence as she was clearly crying out for help and her school had recognised this. No one agency involved had access to all the relevant information and concerns about Ella across the health, social care and education arenas. Evidence given suggested that shared records would assist but the ability to respond to urgent concerns would require a system change.
(4)It was brought to the court’s attention that the new Children’s Wellbeing and Schools bill includes a duty to share information to promote safeguarding. In addition the local authority may convene a strategy meeting under s47 of the Children Act 1989 although the speed of convening a meeting would depend on availability and would obviously not be as swift as for example attending an accident and emergency department. If a multiagency meeting had been convened this may have prevented Ella’s death and such action may reduce the risk of death for other children being in a similar 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 Failure to provide agencies with access to all relevant cross-sector safeguarding information
Wider context from the report “(3) Whilst there were concerns about the level of risk assessment undertaken on 14 November 2023 senior staff at the Trust gave evidence that she did not meet the criteria for admission to a hospital bed. This was difficult to reconcile with the documentary evidence as she was clearly crying out for help and her school had recognised this. No one agency involved had access to all the relevant information and concerns about Ella across the health, social care and education arenas. Evidence given suggested that shared records would assist but the ability to respond to urgent concerns would require a system change.
(4)It was brought to the court’s attention that the new Children’s Wellbeing and Schools bill includes a duty to share information to promote safeguarding. In addition the local authority may convene a strategy meeting under s47 of the Children Act 1989 although the speed of convening a meeting would depend on availability and would obviously not be as swift as for example attending an accident and emergency department. If a multiagency meeting had been convened this may have prevented Ella’s death and such action may reduce the risk of death for other children being in a similar 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 mechanism to convene urgent multi-agency safeguarding meetings
Wider context from the report “(1)During the course of the inquest it became clear that Ella was a child in a complex family situation and showing signs of deterioration of her mental health. Her school had raised concerns about her with social services and taken steps to make sure she was seen by healthcare professionals when she indicated to staff at school she wanted to end her life on 13 November 2023. She was assessed by mental health nursing staff and accepted to the caseload of the Intensive Home Treatment Team. She was seen the following day and told the staff nurse who saw her that she was frightened of her stepfather and had run away from home barefoot and police called but she was brought back home by her mother who “grabbed her face” the morning she was seen. She told the nurse that she did not want to be in the family home and would rather go to prison and would harm herself or others is she had to stay at home.
(2) This disclosure led to the nurse making a Safeguarding Referral but this was made after she left Ella’s home and no urgent steps were taken to remove Ella either to a hospital bed or to ask social services to consider if she should be removed from the family home. Her school had raised concerns about her and she herself had indicated she wished to end her life. Evidence heard at the inquest was that this was the procedure in place and there is no shared access to records for all agencies and no way to convene an urgent multi-agency meeting to determine if Ella was safe to remain at home . Had steps been taken to share information between her school, social services and the mental health providers when she attend the emergency department on 13 November 2023 or early the following day rather than leave her at home she may have been removed from her home and may still be alive today.
” 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 Deliver the national rollout of reforms to family help, multi-agency child protection and family group decision-making, including multi-agency child protection teams.
Verbatim wording from the response “As part of this, the Government’s Families First Partnership programme is delivering the national rollout of reforms to family help, multi-agency child protection and family group decision-making, including delivery of MACPTs. The programme guide sets out the responsibilities of the MACPT members, including to facilitate better communication and information sharing among practitioners and agencies. This is available at: Families First Partnership programme - GOV.UK” Source location 2025-0182 Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England and the integrated care board are responsible for addressing the local concerns and explaining missing safeguarding action and mitigations.
Verbatim wording from the response “I understand that NHS England and Kent and Medway Integrated Care Board have also received this report and I trust that they will adequately address your concerns at the local level. I look forward to reading their responses and working with them on any proposed changes.” Source location 2025-0182 Response from Department of Health and Social Care
Open published response
4 Feb 2025 Dorothy Lilian REID · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 5 Reluctance of patients to attend the emergency department because of long waiting times View source Delays in emergency treatment caused by unavailable inpatient beds View source Unavailability of beds for emergency department patients View source Failure to free hospital beds occupied by patients medically fit for discharge View source Delays in emergency department patients being seen by a doctor View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dorothy Lilian REID · 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
Dorothy Reid, a 91-year-old woman, suffered spinal fractures after a fall and later died from a pulmonary embolism on 3 April 2024. Concerns included delays and poor conditions in the emergency department, the impact of hospital bed shortages on emergency care, and patients’ reluctance to attend hospital because of long waiting times.
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 Reluctance of patients to attend the emergency department because of long waiting times
Wider context from the report “(3) When asked about whether the delays led to a risk of deaths to others evidence was brought to the courts attention that the President of the Royal College of Emergency Medicine has published an analysis of the impact that this is having and that there are a significant number deaths associated with long waits in the emergency department. This, in conjunction with the reluctance of patients to attend the emergency department due to long waiting times clearly gives rise to a risk of future deaths unless something is done.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 emergency treatment caused by unavailable inpatient beds
Wider context from the report “(2) Both attendances at the emergency department were on busy shifts but evidence heard from staff was that this was not unusual and the reasons being that beds in the hospital are blocked by patients who are medically fit for discharge. The evidence heard was that on average around 25% of the hospital beds were filled with patients who did not need to be there which in turn leads to patients who need to be admitted not having a bed to be admitted into . This in turn leads to patients waiting in the emergency department for a bed . This places unnecessary pressure on the emergency departments and leads to delays for those seeking emergency treatment . The evidence heard suggested that this was a national not local problem.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 beds for emergency department patients
Wider context from the report “(1) During the course of the evidence it became clear that on both attendances to the emergency department at QEQM she had to wait on a chair as there were no beds . The first attendance led to such a poor experience that she chose not to go back to hospital when an ambulance was called on 31 March 2024. Had she gone to hospital on 31 March 2024 when advised to do so it is likely that her pulmonary embolus would have been diagnosed in the emergency department and treated and she would not have died when she did. Delays in being seen by a doctor at the second attendance were of concern but were found not to be causative of her death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 free hospital beds occupied by patients medically fit for discharge
Wider context from the report “(2) Both attendances at the emergency department were on busy shifts but evidence heard from staff was that this was not unusual and the reasons being that beds in the hospital are blocked by patients who are medically fit for discharge . The evidence heard was that on average around 25% of the hospital beds were filled with patients who did not need to be there which in turn leads to patients who need to be admitted not having a bed to be admitted into. This in turn leads to patients waiting in the emergency department for a bed. This places unnecessary pressure on the emergency departments and leads to delays for those seeking emergency treatment. The evidence heard suggested that this was a national not local problem.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 emergency department patients being seen by a doctor
Wider context from the report “(1) During the course of the evidence it became clear that on both attendances to the emergency department at QEQM she had to wait on a chair as there were no beds. The first attendance led to such a poor experience that she chose not to go back to hospital when an ambulance was called on 31 March 2024. Had she gone to hospital on 31 March 2024 when advised to do so it is likely that her pulmonary embolus would have been diagnosed in the emergency department and treated and she would not have died when she did. Delays in being seen by a doctor at the second attendance were of concern but were found not to be causative of her death.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase the proportion of patients discharged by or on day seven of admission.
Verbatim wording from the response “The NHS will focus on delivering the following range of practical actions to improve performance in 2025/26:” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reform the Better Care Fund so pooled NHS and local-authority funding supports reducing emergency admissions, delayed discharges and care-home admissions.
Verbatim wording from the response “We are reforming the Better Care Fund to ensure pooled NHS and local authority funding spent on social care contributes to wider efforts to reduce emergency admissions, delayed discharges, and care home admissions. We will continue to join up health and care services by supporting care workers to safely take on further duties to deliver delegated healthcare activities, such as blood pressure checks and other healthcare interventions, so that people can receive more routine checks and care at home without needing to travel to healthcare settings.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase same-day emergency care so more patients are seen, treated and discharged within one day.
Verbatim wording from the response “The NHS will focus on delivering the following range of practical actions to improve performance in 2025/26:” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop local NHS and social-care partnerships to reduce delayed discharges and patients waiting to leave hospital.
Verbatim wording from the response “Regarding the concern raised about bed capacity and delays to patient discharge from hospitals, this government will make sure that hospital departments are no longer blocked due to delayed discharges. By developing local partnership working between the NHS and social care, we will ensure we no longer have over 12,000 patients every day waiting to be discharged.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the NHS mandate and planning guidance prioritising and detailing 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. On the same day NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems. The planning guidance included an implementation target for improving A&E waiting times compared to 2024/25, with a minimum of 78% of patients seen within 4 hours in March 2026.” Source location Response from DHSC
Open published response
31 Jan 2025 Kim Jeannette ROBINSON · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 6 Ease of obtaining online prescriptions View source Failure of online prescribers to access patients’ records during consultations View source Failure to assess suicidal behaviour or thoughts in online consultations View source Failure to limit online prescription quantities according to possible lethal dose View source Lack of prescriber comment functionality for reviewed online consultations View source Failure to require consent and notify current or regular practitioners about online prescriptions 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
Kim Jeannette ROBINSON · 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
Kim Robinson died at home in Suffolk on 12 May 2024 after toxicological analysis identified a significantly toxic level of a medication obtained from an online pharmacy. The report identified concerns that the online prescriber could not access her GP records, the ordering process used incorrect details, and the medication was delivered in a quantity that gave her direct access to a fatal amount. The report stated that the online prescription system needed review.
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 Ease of obtaining online prescriptions
Wider context from the report “1. Following Kim’s tragic death the GP who had prescribed the prescription of ████████ to Kim, reviewed the current online system in place and identified five areas where in his evidence he identified changes could be made.
The GP stated there was:-
a) The need for online prescribers to be able to access a patient’s records (at least the Summary Care Records). These records could be attached to the consultation for review by the prescriber.
b) All patients could be asked for consent to share the details of their prescriptions with their current GP and/or regular practitioner. When consent is given, it was suggested a notice should be sent to these healthcare providers at the same time the medicine is delivered to the patient. Without such consent, the patient’s order should not be accepted.
c) Prescribers could have the ability to add comments when reviewing a consultation, whether it is approved or vetoed.
d) All consultations could include the question: “Have you ever had suicidal behaviour or thoughts?”
e) Prescriptions could be also for smaller quantities, taking into account the possible lethal dose of the medicine. If necessary, dispensing should be limited to weekly or reduced frequencies.
Had these features been present on the on-line system, the GP stated he would not have issued a prescription of ████████ to Kim.
In light of the evidence heard in this case I believe the current system of on-line prescription service needs to be reviewed.
2. It is of note, that the matter of concern regarding the ease in obtaining online prescriptions was previously raised by this court on 15th November 2019 in a Prevention of Future Death report following the tragic death of Deborah Headspeath on 3rd August 2017.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 online prescribers to access patients’ records during consultations
Wider context from the report “1. Following Kim’s tragic death the GP who had prescribed the prescription of ████████ to Kim, reviewed the current online system in place and identified five areas where in his evidence he identified changes could be made.
The GP stated there was:-
a) The need for online prescribers to be able to access a patient’s records (at least the Summary Care Records). These records could be attached to the consultation for review by the prescriber.
b) All patients could be asked for consent to share the details of their prescriptions with their current GP and/or regular practitioner. When consent is given, it was suggested a notice should be sent to these healthcare providers at the same time the medicine is delivered to the patient. Without such consent, the patient’s order should not be accepted.
c) Prescribers could have the ability to add comments when reviewing a consultation, whether it is approved or vetoed.
d) All consultations could include the question: “Have you ever had suicidal behaviour or thoughts?”
e) Prescriptions could be also for smaller quantities, taking into account the possible lethal dose of the medicine. If necessary, dispensing should be limited to weekly or reduced frequencies.
Had these features been present on the on-line system, the GP stated he would not have issued a prescription of ████████ to Kim.
In light of the evidence heard in this case I believe the current system of on-line prescription service needs to be reviewed.
2. It is of note, that the matter of concern regarding the ease in obtaining online prescriptions was previously raised by this court on 15th November 2019 in a Prevention of Future Death report following the tragic death of Deborah Headspeath on 3rd August 2017.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to assess suicidal behaviour or thoughts in online consultations
Wider context from the report “1. Following Kim’s tragic death the GP who had prescribed the prescription of ████████ to Kim, reviewed the current online system in place and identified five areas where in his evidence he identified changes could be made.
The GP stated there was:-
a) The need for online prescribers to be able to access a patient’s records (at least the Summary Care Records). These records could be attached to the consultation for review by the prescriber.
b) All patients could be asked for consent to share the details of their prescriptions with their current GP and/or regular practitioner. When consent is given, it was suggested a notice should be sent to these healthcare providers at the same time the medicine is delivered to the patient. Without such consent, the patient’s order should not be accepted.
c) Prescribers could have the ability to add comments when reviewing a consultation, whether it is approved or vetoed.
d) All consultations could include the question: “Have you ever had suicidal behaviour or thoughts?”
e) Prescriptions could be also for smaller quantities, taking into account the possible lethal dose of the medicine. If necessary, dispensing should be limited to weekly or reduced frequencies.
Had these features been present on the on-line system, the GP stated he would not have issued a prescription of ████████ to Kim.
In light of the evidence heard in this case I believe the current system of on-line prescription service needs to be reviewed.
2. It is of note, that the matter of concern regarding the ease in obtaining online prescriptions was previously raised by this court on 15th November 2019 in a Prevention of Future Death report following the tragic death of Deborah Headspeath on 3rd August 2017.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to limit online prescription quantities according to possible lethal dose
Wider context from the report “1. Following Kim’s tragic death the GP who had prescribed the prescription of ████████ to Kim, reviewed the current online system in place and identified five areas where in his evidence he identified changes could be made.
The GP stated there was:-
a) The need for online prescribers to be able to access a patient’s records (at least the Summary Care Records). These records could be attached to the consultation for review by the prescriber.
b) All patients could be asked for consent to share the details of their prescriptions with their current GP and/or regular practitioner. When consent is given, it was suggested a notice should be sent to these healthcare providers at the same time the medicine is delivered to the patient. Without such consent, the patient’s order should not be accepted.
c) Prescribers could have the ability to add comments when reviewing a consultation, whether it is approved or vetoed.
d) All consultations could include the question: “Have you ever had suicidal behaviour or thoughts?”
e) Prescriptions could be also for smaller quantities, taking into account the possible lethal dose of the medicine. If necessary, dispensing should be limited to weekly or reduced frequencies.
Had these features been present on the on-line system, the GP stated he would not have issued a prescription of ████████ to Kim.
In light of the evidence heard in this case I believe the current system of on-line prescription service needs to be reviewed.
2. It is of note, that the matter of concern regarding the ease in obtaining online prescriptions was previously raised by this court on 15th November 2019 in a Prevention of Future Death report following the tragic death of Deborah Headspeath on 3rd August 2017.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 prescriber comment functionality for reviewed online consultations
Wider context from the report “1. Following Kim’s tragic death the GP who had prescribed the prescription of ████████ to Kim, reviewed the current online system in place and identified five areas where in his evidence he identified changes could be made.
The GP stated there was:-
a) The need for online prescribers to be able to access a patient’s records (at least the Summary Care Records). These records could be attached to the consultation for review by the prescriber.
b) All patients could be asked for consent to share the details of their prescriptions with their current GP and/or regular practitioner. When consent is given, it was suggested a notice should be sent to these healthcare providers at the same time the medicine is delivered to the patient. Without such consent, the patient’s order should not be accepted.
c) Prescribers could have the ability to add comments when reviewing a consultation, whether it is approved or vetoed.
d) All consultations could include the question: “Have you ever had suicidal behaviour or thoughts?”
e) Prescriptions could be also for smaller quantities, taking into account the possible lethal dose of the medicine. If necessary, dispensing should be limited to weekly or reduced frequencies.
Had these features been present on the on-line system, the GP stated he would not have issued a prescription of ████████ to Kim.
In light of the evidence heard in this case I believe the current system of on-line prescription service needs to be reviewed.
2. It is of note, that the matter of concern regarding the ease in obtaining online prescriptions was previously raised by this court on 15th November 2019 in a Prevention of Future Death report following the tragic death of Deborah Headspeath on 3rd August 2017.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 require consent and notify current or regular practitioners about online prescriptions
Wider context from the report “1. Following Kim’s tragic death the GP who had prescribed the prescription of ████████ to Kim, reviewed the current online system in place and identified five areas where in his evidence he identified changes could be made.
The GP stated there was:-
a) The need for online prescribers to be able to access a patient’s records (at least the Summary Care Records). These records could be attached to the consultation for review by the prescriber.
b) All patients could be asked for consent to share the details of their prescriptions with their current GP and/or regular practitioner. When consent is given, it was suggested a notice should be sent to these healthcare providers at the same time the medicine is delivered to the patient. Without such consent, the patient’s order should not be accepted.
c) Prescribers could have the ability to add comments when reviewing a consultation, whether it is approved or vetoed.
d) All consultations could include the question: “Have you ever had suicidal behaviour or thoughts?”
e) Prescriptions could be also for smaller quantities, taking into account the possible lethal dose of the medicine. If necessary, dispensing should be limited to weekly or reduced frequencies.
Had these features been present on the on-line system, the GP stated he would not have issued a prescription of ████████ to Kim.
In light of the evidence heard in this case I believe the current system of on-line prescription service needs to be reviewed.
2. It is of note, that the matter of concern regarding the ease in obtaining online prescriptions was previously raised by this court on 15th November 2019 in a Prevention of Future Death report following the tragic death of Deborah Headspeath on 3rd August 2017.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The prescriber is responsible for decisions on prescription quantities, while service providers must maintain adequate controls and may advise on prescription duration.
Verbatim wording from the response “Relevant to your concern that ‘prescriptions could be also for smaller quantities, taking into account the possible lethal dose of the medicine. If necessary, dispensing should be limited to weekly or reduced frequencies’, The responsibility for prescribing rests with the prescriber who has clinical responsibility for that particular aspect of a patient’s care. Issuing shorter prescriptions could give the prescriber the opportunity to review the patient’s medicines, which is important for some groups of patients and may therefore be particularly appropriate in some cases. The service provider, whether NHS commissioner or private sector provider has a responsibility to ensure that adequate controls are in place, and they may also issue advice to prescribers about the length of time for which prescriptions should be issued.” 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 If an appropriate organisation requires a standardised suicidal-behaviour question, the GPhC would monitor its inclusion through inspections.
Verbatim wording from the response “In your report you suggest that all consultations could include the question: “Have you ever had suicidal behaviour or thoughts?” On this point, the GPhC expects pharmacies to carry out a risk assessment for every part of the service they provide. If an appropriate organisation stated that this question should be included, then the GPhC would monitor this through its inspection processes.” Source location Response from DHSC
Open published response
31 Jan 2025 Nicola Emma OWENS · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 4 Unavailability of ambulances for attending patients View source Lack of staff and room for patients brought in via ambulance View source Delays in hospital handover of ambulance patients View source Backlog of patients fit for discharge awaiting social care packages View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nicola Emma OWENS · 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
Nicola Emma Owens collapsed at work on 4 October 2024 and, after a delay of 7 hours and 28 minutes before an ambulance arrived, suffered a cardiac arrest and died in hospital at 00:25 on 5 October 2024. The report identified concerns about ambulance unavailability, hospital handover delays, and backlogs of patients awaiting social care packages, which reduced ambulance availability for seriously ill patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of ambulances for attending patients
Wider context from the report “The delay in an ambulance attending patients due to the unavailability of ambulances . This delay being significantly contributed to by the handover delays in hospitals. A significant factor contributing to the handover delays in hospitals being the backlog of patients who are fit for discharge but awaiting social care packages. Overall, this entails a lack of staff and room for those patients who are brought in via ambulance thus requiring ambulance crews to remain on hospital premises reducing their ability to attend seriously ill patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of staff and room for patients brought in via ambulance
Wider context from the report “The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals. A significant factor contributing to the handover delays in hospitals being the backlog of patients who are fit for discharge but awaiting social care packages. Overall, this entails a lack of staff and room for those patients who are brought in via ambulance thus requiring ambulance crews to remain on hospital premises reducing their ability to attend seriously ill patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in hospital handover of ambulance patients
Wider context from the report “The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals. A significant factor contributing to the handover delays in hospitals being the backlog of patients who are fit for discharge but awaiting social care packages. Overall, this entails a lack of staff and room for those patients who are brought in via ambulance thus requiring ambulance crews to remain on hospital premises reducing their ability to attend seriously ill patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Backlog of patients fit for discharge awaiting social care packages
Wider context from the report “The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals. A significant factor contributing to the handover delays in hospitals being the backlog of patients who are fit for discharge but awaiting social care packages . Overall, this entails a lack of staff and room for those patients who are brought in via ambulance thus requiring ambulance crews to remain on hospital premises reducing their ability to attend seriously ill patients.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the 2025 NHS mandate 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. On the same day NHS England published the 2025-26 planning guidance that accompanied the operational delivery detail for local NHS systems. The planning guidance included an implementation target for improving the average Category 2 ambulance response times to no more than 30 minutes across 2025-26, and practical actions focused on reducing avoidable ambulance dispatches and conveyances and ambulance handover delays.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop NHS and social care local partnerships to reduce delayed discharges and ensure hospital departments are no longer blocked by patients awaiting discharge.
Verbatim wording from the response “Regarding the concern raised about delays to patient discharge from hospitals, this government will make sure that hospital departments are no longer blocked due to delayed discharges. By developing local partnership working between the NHS and social care, we will ensure we no longer have over 12,000 patients every day waiting to be discharged.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clinically navigate, validate and appropriately triage all Category 3 and 4 999 ambulance calls through control centres or Single Points of Access.
Verbatim wording from the response “• ensuring all 999 ambulance calls classified as Category 3 and 4 are clinically navigated, validated and where appropriate triaged in ambulance control centres, or in Single Points of Access.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work towards 15-minute hospital handovers and implement joint arrangements preventing handovers from exceeding 45 minutes.
Verbatim wording from the response “• working towards delivering hospital handovers within 15 minutes, and implementing joint working arrangements that ensure that no handover takes longer than 45 minutes,” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve ambulance hear-and-treat rates, including clinician-provided telephone advice and treatment for more Category 2 incidents.
Verbatim wording from the response “• improving ambulance ‘hear and treat’ service rates, including increasing the proportion of Category 2 ambulance incidents where an ambulance clinician provides advice and treatment over the phone,” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reform the Better Care Fund so pooled NHS and local-authority funding supports reductions in emergency admissions, delayed discharges and care-home admissions.
Verbatim wording from the response “We are reforming the Better Care Fund to ensure pooled NHS and local authority funding spent on social care contributes to wider efforts to reduce emergency admissions, delayed discharges, and care home admissions. We will continue to join up health and care services by supporting care workers to safely take on further duties to deliver delegated healthcare activities, such as blood pressure checks and other healthcare interventions, so that people can receive more routine checks and care at home without needing to travel to healthcare settings.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish 2025–26 NHS planning guidance with a target for average Category 2 ambulance responses and actions to reduce dispatches, conveyances and handover delays.
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. On the same day NHS England published the 2025-26 planning guidance that accompanied the operational delivery detail for local NHS systems. The planning guidance included an implementation target for improving the average Category 2 ambulance response times to no more than 30 minutes across 2025-26, and practical actions focused on reducing avoidable ambulance dispatches and conveyances and ambulance handover delays.” Source location Response from DHSC
Open published response
29 Jan 2025 Carla Marie SMITH · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2 Excessive waiting times for urgent and routine referrals View source Lack of monitoring and review of patients on routine or urgent waiting lists View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Carla Marie 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
Carla Marie SMITH died on 7 June 2023 after rapidly progressing metastatic endometrial cancer. The report identified missed opportunities in referral and use of the correct pathway, delays in laboratory results, and lengthy waiting lists. Concerns included the risk that patients may deteriorate while waiting and the lack of systems to monitor patients on routine or urgent waiting lists.
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 Excessive waiting times for urgent and routine referrals
Wider context from the report “1. During the course of the evidence, I heard from Consultants at two hospitals, and read evidence from others. The evidence I heard is that, at that time there were significant waiting lists, even for those on an urgent pathway . I heard that these issues persist and that, in relation to gynaecology referrals which was the subject of this inquest, where the expected waiting time would previously be 4-6 weeks for an urgent referral, one hospital has a waiting time of 18 weeks, the other 30 weeks (and 60 weeks for routine) . I was advised by one Consultant that they do not know how they can catch up with this backlog . I am aware that this is not a problem that is unique to just the two Trusts from whom evidence was heard.
2. The cause for concern is that some patients may significantly deteriorate while on such lengthy waiting lists. In some cases, this may mean that they lose some treatment options due to their condition advancing. This leads to a risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of monitoring and review of patients on routine or urgent waiting lists
Wider context from the report “3. The other concern I have following the evidence heard, is that if someone is on a routine or urgent waiting list, there is no requirement or system in place to monitor their progress . I was advised that those referred under a 2 week wait (which I am now advised has been changed to a 28 day wait) for suspected cancer, will be monitored to ensure that the timescale is met. There is no such requirement for the other waiting lists . This may lead to patients being left waiting for excessive periods, without any requirement for their case to be reviewed to ascertain if it remains suitable for such a lengthy wait, or if a new referral needs to be made on a different pathway .
” 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 Restore the 18-week Referral to Treatment standard, with 92% of patients receiving treatment within that timeframe.
Verbatim wording from the response “commitment to reducing patient wait times and improving access to timely care. A key focus is restoring the 18-week Referral to Treatment standard, ensuring that 92% of patients receive treatment within this timeframe. Addressing the backlog and delays in gynaecology, which have faced increasing demand and performance challenges, is an important part of the overall return to constitutional standards.” Source location Response from DHSC
Open published response
24 Jan 2025 Andrew Dominic HEYS · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Failure of health information systems to enable authorised cross-provider access to patient records View source Lack of training for clinicians in accessing patients' GP records View source Lack of training for out-of-hours clinicians in following referral pathways View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew Dominic HEYS · 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 Dominic HEYS received a Covid-19 booster vaccination in December 2021 and subsequently suffered from Auto-Immune Encephalopathy. On 12 March 2024, he fell into the Manchester Ship Canal from a bridge, and his body was discovered four days later. Concerns included inadequate training for an out-of-hours GP in following referral pathways and accessing patient records, as well as incompatible health-record IT systems that prevented health professionals from accessing records held elsewhere in the NHS.
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 health information systems to enable authorised cross-provider access to patient records
Wider context from the report “During the course of the evidence, the GP, who was acting on behalf of BARDOC, the out of hours provider, indicated to me that she had never been trained by BARDOC, in how to follow their 'pathways'; this meant that she 'closed' the call after speaking to the patient, rather than returning it to the Ambulance Service as should have happened. She was also confused about how she could access the patient's own GP records; again, she said she had not had any training in this regard.
During the course of the evidence, I heard, yet again, the common complaint that one health professional is unable to access the health records of the patient held by another health professional . In this case, the manager of the 111 Helpline agreed that the various IT systems do not "talk to each other" . It is of concern to me as to why all bona fide health professionals cannot have access to all health data held anywhere within the NHS .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of training for clinicians in accessing patients' GP records
Wider context from the report “During the course of the evidence, the GP, who was acting on behalf of BARDOC, the out of hours provider, indicated to me that she had never been trained by BARDOC, in how to follow their 'pathways'; this meant that she 'closed' the call after speaking to the patient, rather than returning it to the Ambulance Service as should have happened. She was also confused about how she could access the patient's own GP records; again, she said she had not had any training in this regard.
During the course of the evidence, I heard, yet again, the common complaint that one health professional is unable to access the health records of the patient held by another health professional. In this case, the manager of the 111 Helpline agreed that the various IT systems do not "talk to each other". It is of concern to me as to why all bona fide health professionals cannot have access to all health data held anywhere within the NHS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of training for out-of-hours clinicians in following referral pathways
Wider context from the report “During the course of the evidence, the GP, who was acting on behalf of BARDOC, the out of hours provider, indicated to me that she had never been trained by BARDOC, in how to follow their 'pathways' ; this meant that she 'closed' the call after speaking to the patient, rather than returning it to the Ambulance Service as should have happened. She was also confused about how she could access the patient's own GP records; again, she said she had not had any training in this regard.
During the course of the evidence, I heard, yet again, the common complaint that one health professional is unable to access the health records of the patient held by another health professional. In this case, the manager of the 111 Helpline agreed that the various IT systems do not "talk to each other". It is of concern to me as to why all bona fide health professionals cannot have access to all health data held anywhere within the NHS.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue rolling out Electronic Patient Records and support trusts to replace, extend, or optimise existing systems.
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 for Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a single patient record, beginning its rollout from 2028 with maternity care.
Verbatim wording from the response “Going beyond this, the Government’s 10 Year Health Plan commits to delivery of a single patient record (SPR). This will provide a comprehensive patient record, bringing together all of a patient’s medical records into one place. We have been engaging with the public to help shape our plans, including what information they would like to see included in a single patient record and we will continue to talk to the public and to health and care professionals as we design the SPR to ensure their needs are reflected. The SPR will begin to go live from 2028 and be rolled out first in maternity care.” Source location Response from Department for Health and Social Care
Open published response
15 Jan 2025 Robert John McGowan · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Failure to overcome cultural, structural and systemic barriers to physical healthcare for people with autism and complex mental health needs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Robert John McGowan · 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
Robert John McGowan died at Stepping Hill Hospital, Stockport, on 13 August 2024 from complications arising from partially treated spontaneous bacterial endocarditis, against a background of autism and complex mental health needs. The concern was that cultural, structural and systemic barriers to accessing physical healthcare contributed to the bacterial endocarditis being only partially treated, despite advocacy, individual adjustments and a Health Passport.
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 overcome cultural, structural and systemic barriers to physical healthcare for people with autism and complex mental health needs
Wider context from the report “I am concerned that, as a consequence of living with Autism and complex mental health needs, Mr McGowan encountered cultural, structural and systemic barriers to receiving treatment for his physical health needs , the result of which was that the bacterial endocarditis which led to his death had only been partially treated. The court heard evidence that these barriers continued to exist notwithstanding advocacy provided by a charity which supported Mr McGowan, a range of individual adjustments healthcare professionals sought to make to facilitate his access to care and treatment, and the fact he had a Health Passport.
” 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 Roll out Oliver McGowan Mandatory Training on Learning Disability and Autism for healthcare staff.
Verbatim wording from the response “We are taking action to increase awareness and understanding of autism amongst healthcare professionals, to help ensure that staff have the right knowledge and skills to provide safe and informed care. Under the Health and Care Act 2022, service providers registered with the Care Quality Commission (CQC) are required to ensure their staff receive learning disability and autism training appropriate to their role. This training will also help to improve the culture within health and social care services, including shifting attitudes and approach to ensure people with a learning disability and autistic people are treated safely, respectfully and confidently.” Source location Response from Department of Health and Social Care
Open published response
13 Jan 2025 Aarav Pal CHOPRA · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 6 Lack of a mechanism to evidence trainees' experience and competence across hospital trusts View source Lack of a mechanism to identify and communicate individual patient risk factors View source Lack of access to all clinical records when planning treatment View source Lack of a way to obtain consent when a trainee performs a procedure View source Failure to learn from deaths at the earliest opportunity View source Lack of guidance for prophylactic antibiotics in severely immunocompromised patients 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
Aarav Pal CHOPRA · 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
Aarav Pal CHOPRA died on 22 November 2023 after an intercostal artery was damaged during a liver biopsy, causing a haemothorax, cardiac arrest and hypoxic brain injury. The report identified concerns about inadequate planning and communication, delayed recognition and treatment of the haemothorax, unclear decision-making, trainee competence, consent, patient risk factors, prophylactic antibiotics, learning from deaths and access to complete electronic records.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism to evidence trainees' experience and competence across hospital trusts
Wider context from the report “2. Experience and competence of trainees: The inquest heard evidence that there was confusion around the experience and level of the trainee involved. He was thought to be an ST6 when he was an ST4. My concern is that there is no mechanism to evidence trainees experience and competence when they travel to various different hospital trusts as part of their 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 a mechanism to identify and communicate individual patient risk factors
Wider context from the report “4. Individual patient risk factors: Aarav had a complex medical background and several risk factors for any procedure. My concern is that there is currently no mechanism to identify individual patient’s risk factors so that all clinicians involved in their care are aware .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 access to all clinical records when planning treatment
Wider context from the report “6. Electronic patient records: I heard evidence that the lack of electric medical records meant clinicians found it difficult to see all of the patient’s medication details . My concern is that critical information can be missed if clinicians do not have access to all the clinical records when planning treatment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a way to obtain consent when a trainee performs a procedure
Wider context from the report “3. Consent forms: The parents of Aarav were unaware that a trainee would be doing the liver biopsy. My concern is that there is currently no way to obtain consent when a trainee will be doing the procedure .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 learn from deaths at the earliest opportunity
Wider context from the report “5. Learning from deaths: The initial M&M meeting after Aarav's death was described as inadequate. My concern is that there was no immediate learning from this tragedy and further consideration is needed to ensure a safe and effective mechanism to properly learn from deaths at the earliest opportunity .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 prophylactic antibiotics in severely immunocompromised patients
Wider context from the report “1. Prophylactic antibiotics for severely immunocompromised patients: The inquest heard evidence that patients like Aarav who are immunocompromised require additional prophylactic antibiotics for procedures. This is not covered in the current NICE guidelines. My concern is that there is currently no guidance for the use of prophylactic antibiotics in severely immunocompromised patients .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current consent forms and supervised trainee procedures are considered to work largely effectively, so specifying the individual practitioner is not proposed.
Verbatim wording from the response “The National Team Children and Young People, via NHS England, have confirmed that the current consent forms specifically state that the consent does not specify which individual will undertake a procedure.” 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 Birmingham Women’s and Children’s NHS Foundation Trust will address concerns about the inadequate mortality and morbidity meeting in its own response.
Verbatim wording from the response “5. Learning from deaths” 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 Specialist medical societies, rather than NICE, are considered best placed to develop guidance on prophylactic antibiotics for immunocompromised liver-transplant children.
Verbatim wording from the response “NICE feel that this is a highly specialised area that is likely to have limited evidence, and therefore, the subject would be best covered by a consensus-based clinical practice guideline developed by a specialist medical society.” Source location Response from DHSC
Open published response
Concerns raised 1 Restrictions preventing pharmacists from issuing equivalent medication strengths to provide the same dose View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ava Grace HODGKINSON · 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
Ava Grace HODGKINSON died in cardiac arrest at Ormskirk District General Hospital on 14 December 2022, following overwhelming sepsis caused by Group A Streptococcus infection. A delay in receiving antibiotics occurred because the prescribed strength was unavailable and the pharmacy could not issue a different strength that would have provided the same dose without an amended prescription.
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 Restrictions preventing pharmacists from issuing equivalent medication strengths to provide the same dose
Wider context from the report “(1) In evidence at the inquest it was explained that the Ava had seen her GP who had prescribed amoxicillin with a dose of 250mg/5ml. The pharmacy did not have this strength in stock but did have amoxicillin 125mg/5ml in stock but could not issue this as restrictions currently in place prevent a pharmacist issuing any different strength of medication without an amended prescription, even where the medication can be provided to enable the same dose to be administered (here Ava's parents could have been instructed to provide 10ml enabling the same dose of antibiotics to be provided). This led to a delay in Ava receiving antibiotics . Evidence from the Department of Health and Social Care included that this issue was being actively considered but it was explained the issue was complex and any change was likely to need public consultation and ministerial support. It was also explained that it was not possible to provide any timeframe for any appropriate steps to be taken to consider changing the restrictions preventing pharmacists from issuing medication where they can provide the same dosage of the same medication in a different denomination .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore new flexibilities allowing pharmacists, in appropriate circumstances, to supply alternative doses or formulations.
Verbatim wording from the response “Nevertheless, I am committed to my officials exploring new flexibilities. There has been a recent programme of engagement, since December 2024, as part of which my officials have discussed possibilities with stakeholders such as GP representatives, pharmacy bodies and patient groups. The stakeholder feedback has been sufficiently positive that the Government is minded, subject to the normal machinery of Government clearance processes, to proceed to a formal, public consultation.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct and publish a public consultation on proposed medication-supply flexibilities, subject to governmental clearances and Northern Ireland involvement.
Verbatim wording from the response “Nevertheless, I am committed to my officials exploring new flexibilities. There has been a recent programme of engagement, since December 2024, as part of which my officials have discussed possibilities with stakeholders such as GP representatives, pharmacy bodies and patient groups. The stakeholder feedback has been sufficiently positive that the Government is minded, subject to the normal machinery of Government clearance processes, to proceed to a formal, public consultation.” Source location Response from DHSC
Open published response
9 Jan 2025 Maria Simpson · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 2 Lack of interoperable electronic patient-record systems between general practices View source Failure of case management systems to store all historic patient documents electronically View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Maria Simpson · 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
Maria Simpson died on 24 August 2022 from massive recurrent pulmonary thromboembolism and deep vein thrombosis. The report states that referrals concerning anticoagulation were returned or not accessed before her death, and that this probably made more than a minimal contribution to her death. It also identifies concerns about non-uniform electronic record systems, delays when transferring records, and difficulty accessing historic referral information.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of interoperable electronic patient-record systems between general practices
Wider context from the report “Evidence was given in the inquest to the effect that medical General Practitioners have no uniform national case management system for electronic storage of patients’ records . This leads to a situation whereby, upon transfer of patient records from one practice to another, the receiving practice is obliged to input all the records afresh if the practices operate different systems . This can lead to delay in the compilation of records .
Further, it appears that a case management system is unable to store electronically all historic documents such as referral letters from one clinician to another, due to electronic capacity issues. This leads to a situation where some patient information is stored electronically and some in paper form making it difficult for the GP to note quickly all relevant patient information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 case management systems to store all historic patient documents electronically
Wider context from the report “Evidence was given in the inquest to the effect that medical General Practitioners have no uniform national case management system for electronic storage of patients’ records. This leads to a situation whereby, upon transfer of patient records from one practice to another, the receiving practice is obliged to input all the records afresh if the practices operate different systems. This can lead to delay in the compilation of records.
Further, it appears that a case management system is unable to store electronically all historic documents such as referral letters from one clinician to another, due to electronic capacity issues . This leads to a situation where some patient information is stored electronically and some in paper form making it difficult for the GP to note quickly all relevant patient information .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National rollout of the Document Repository is conditional on securing funding.
Verbatim wording from the response “a National Document Repository. The National Document Repository is supporting storage of and access to scanned Lloyd George records. The system is due to be rolled out nationally in financial year 2025/26, subject to securing funding.” 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 Existing GMS requirements and GP2GP enable electronic patient records to transfer between practices using different systems.
Verbatim wording from the response “The NHS General Medical Services (GMS) contract regulations stipulate that contractors must keep ‘adequate’ patient records either on forms provided by NHSE, in computerised records, or a combination of both. The contract also states that any computer system must meet the requirements set out in the GPIT Operating model and that the contractor must have regard for the guidance laid out in Digital Primary Care: Good Practice Guidelines for GP electronic patient records.” Source location Response from DHSC
Open published response
2 Jan 2025 Joseph Benjamin FORBES BLACK · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Restricted access to naloxone kits through substance misuse services View source Failure of supported accommodation providers and mental health NHS trusts to provide naloxone kits to known drug users View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joseph Benjamin FORBES BLACK · 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
Joseph Forbes Black was found deceased at his home on 9 August 2023, having died from acute polydrug toxicity involving heroin adulterated with protonitazene and metonitazene. The report’s principal concern was that naloxone kits were not permitted to be provided by the supported accommodation provider or mental health NHS Trust to known drug users, while access was concentrated through substance misuse services with which many drug users were not engaged. The concern was considered potentially nationwide and heightened by the increased incidence of heroin adulterated with potent synthetic opioids.
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 Restricted access to naloxone kits through substance misuse services
Wider context from the report “The evidence revealed that, neither the supported accommodation provider nor the mental health NHS Trust that was treating Mr Forbes Black were permitted to give naloxone kits to their residents/patients who were known drug users.
In my experience, from this inquest and others, a significant proportion of illicit drug users are not engaged with or decline to engage with substance misuse services for a number of possible reasons. The evidence in the inquest was that, if a drug-user wanted to have naloxone in their possession as a safety-net measure, they would need to obtain this from a local substance misuse service .
I am concerned that this set of circumstances raises the risk of future deaths occurring because the provision of naloxone kits could be made more widely available to those most likely to need them. The present situation appears to be that naloxone is most easily accessed through the very service(s) that many drug-users are not engaged with . My concern, based on the evidence heard at this inquest and others that I am aware of, is that this is not a localised matter and is more likely a nationwide issue and that action should be taken more widely.
It further seems to me that the need for action is heightened by the increased incidence of heroin having been adulterated with ‘nitazenes’ (particularly potent synthetic opioid drugs), which increases the risk of drug users unwittingly overdosing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 supported accommodation providers and mental health NHS trusts to provide naloxone kits to known drug users
Wider context from the report “The evidence revealed that, neither the supported accommodation provider nor the mental health NHS Trust that was treating Mr Forbes Black were permitted to give naloxone kits to their residents/patients who were known drug users .
In my experience, from this inquest and others, a significant proportion of illicit drug users are not engaged with or decline to engage with substance misuse services for a number of possible reasons. The evidence in the inquest was that, if a drug-user wanted to have naloxone in their possession as a safety-net measure, they would need to obtain this from a local substance misuse service.
I am concerned that this set of circumstances raises the risk of future deaths occurring because the provision of naloxone kits could be made more widely available to those most likely to need them. The present situation appears to be that naloxone is most easily accessed through the very service(s) that many drug-users are not engaged with. My concern, based on the evidence heard at this inquest and others that I am aware of, is that this is not a localised matter and is more likely a nationwide issue and that action should be taken more widely.
It further seems to me that the need for action is heightened by the increased incidence of heroin having been adulterated with ‘nitazenes’ (particularly potent synthetic opioid drugs), which increases the risk of drug users unwittingly overdosing.
” 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 Amend regulations to expand take-home naloxone access beyond drug and alcohol treatment services.
Verbatim wording from the response “I am pleased to say that we have already taken action on this critical issue. On 2nd December 2024, the Government amended the Human Medicines Regulations 2012 to expand access to naloxone beyond drug and alcohol treatment services. There are two key changes in the legislation to be aware of. The first increases the number of services and professionals specified in the regulations that are able to give out take home naloxone (for example nurses, paramedics, police officers and probation officers) therefore increasing the likelihood of those who are most vulnerable receiving it, regardless of whether they are engaged in drug and alcohol treatment. The second enables the creation of a registration service for services and professionals that could not be explicitly named in the legislation through route one – for example, supported accommodation services.” Source location Response from DHSC
Open published response
20 Dec 2024 Antony Williamson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Inter-Trust communication channels failing between geographically proximate NHS Trusts View source Lack of a formal framework for inter-specialty communication View source Failure of specialties to communicate about patients’ plans and actions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Antony Williamson · 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
Antony Williamson experienced chronic pelvic pain and associated mental health difficulties, including increasing suicidal thoughts, before leaving home on 19 December 2023 and entering cold water. His body was found in the River Mersey on 17 March 2024, and the inquest concluded that he died from dry drowning and took his own life while experiencing hopelessness about the investigation and treatment of his pelvic pain. The report identified a lack of liaison and communication between the medical and mental health specialties involved in his care, with no formal framework to facilitate inter-specialty communication in complex cases.
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 Inter-Trust communication channels failing between geographically proximate NHS Trusts
Wider context from the report “Throughout the inquest, it was apparent that save for the referral by the Urology team to the Pain Service in September 2023, there was no liaison or communication between any of the specialties involved in Mr Williamson’s care, which resulted in a lack of understanding on the part of each specialty of the plans and actions of the others.
The inquest was told that there is a significant proportion of patients who are referred to the Pain Service who suffer poor mental health and who are therefore also under the care of mental health teams in the community.
The inquest heard that there is no formal framework (other than in cancer care and one specialist area of surgery) either locally or nationally to facilitate inter-specialty communication, particularly in complex and dynamic cases and further, that the existing channels of communication are more problematic between different NHS Trusts even within the same geographical area .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal framework for inter-specialty communication
Wider context from the report “Throughout the inquest, it was apparent that save for the referral by the Urology team to the Pain Service in September 2023, there was no liaison or communication between any of the specialties involved in Mr Williamson’s care, which resulted in a lack of understanding on the part of each specialty of the plans and actions of the others.
The inquest was told that there is a significant proportion of patients who are referred to the Pain Service who suffer poor mental health and who are therefore also under the care of mental health teams in the community.
The inquest heard that there is no formal framework (other than in cancer care and one specialist area of surgery) either locally or nationally to facilitate inter-specialty communication, particularly in complex and dynamic cases and further, that the existing channels of communication are more problematic between different NHS Trusts even within the same geographical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 specialties to communicate about patients’ plans and actions
Wider context from the report “Throughout the inquest, it was apparent that save for the referral by the Urology team to the Pain Service in September 2023, there was no liaison or communication between any of the specialties involved in Mr Williamson’s care , which resulted in a lack of understanding on the part of each specialty of the plans and actions of the others .
The inquest was told that there is a significant proportion of patients who are referred to the Pain Service who suffer poor mental health and who are therefore also under the care of mental health teams in the community.
The inquest heard that there is no formal framework (other than in cancer care and one specialist area of surgery) either locally or nationally to facilitate inter-specialty communication, particularly in complex and dynamic cases and further, that the existing channels of communication are more problematic between different NHS Trusts even within the same geographical area.
” Open source report
19 Dec 2024 Andrew Michael Lewis · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 3 Persistent ambulance queuing at hospitals View source Lack of oversight of ambulance service delay concerns View source Sustained excessive ambulance service operational pressure View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew Michael Lewis · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew Michael Lewis died at home on 7 May 2024 after calling 111 with weakness in his legs and an earlier fall. An ambulance arrived about 10 hours after his first call, although the call had been categorised as requiring attendance within two hours; the report states there was simply no ambulance available to send earlier. The inquest recorded the cause of death as acute on chronic gastrointestinal haemorrhage, bleeding oesophageal varices, alcoholic liver cirrhosis, and low volume subdural haemorrhage, with the conclusion of an alcohol-related death contributed to by head injury.
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 Persistent ambulance queuing at hospitals
Wider context from the report “• I have also been provided with data regarding the number of hours that ambulances have spent queuing at hospitals in the last 3 months (September to November 2024). This amounts to 23,253 hours. This is an average of 255.5 hours across the service every single day.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 oversight of ambulance service delay concerns
Wider context from the report “2. There appears to be no oversight of this issue , and a number of ambulance trusts have not responded to these reports at all.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Sustained excessive ambulance service operational pressure
Wider context from the report “• SCAS has been at REAP 3 or above for 90% of this time period. They have been constantly at REAP 4 since 9 October 2024.
• The lowest escalation level that this ambulance service has been at in this period is REAP 2. They have never been at steady state (REAP 1) during this period.
” 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 Set out lessons learned from winter pressures on urgent and emergency care services.
Verbatim wording from the response “In addition, by this Spring we will also 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 improve services ahead of next winter.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Put improvements in urgent and emergency care services in place ahead of the following winter.
Verbatim wording from the response “In addition, by this Spring we will also 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 improve services ahead of next winter.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the NHS mandate and planning guidance specifying ambulance response-time targets and actions to reduce avoidable dispatches, conveyances and handover delays.
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. On the same day NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems. The planning guidance included an implementation target for improving the average Category 2 ambulance response times to no more than 30 minutes across 2025-26, and practical actions focused on reducing avoidable ambulance dispatches and conveyances and ambulance handover delays.” Source location Response from DHSC
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations