17 Dec 2024 Susan Marie Karakoc · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 3 Search engines readily returning websites selling potentially fatal prescription medications View source Failure of prescription medication supply-chain legitimacy monitoring to prevent ready online supply View source Failure of systems to detect criminal medication supply enterprises and alert relevant authorities View source
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AI-generated summary
Susan Marie Karakoc · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Susan Marie Karakoc collapsed at home on 1 December 2023 and died in hospital the following day after suffering a hypoxic brain injury. The report states that she obtained prescription medications from online sources selling medicines off-label, and that toxicological examination identified toxicity associated with the chain of events leading to her death. Concerns included the ready availability of such websites through search engines, inadequate monitoring of online medication supply chains, and ineffective detection of financial services supporting criminal enterprises.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Search engines readily returning websites selling potentially fatal prescription medications
Wider context from the report “1. There is evidence of search engines readily returning websites which sell prescription medications , including those that sell highly addictive sleeping tablets and painkillers which can and do cause fatalities . I am concerned how readily search engines return websites such as these ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 prescription medication supply-chain legitimacy monitoring to prevent ready online supply
Wider context from the report “2. I am concerned that the current system for monitoring the legitimacy of supply chains for medications available in England and Wales via prescription is not preventing the ready supply of such medications online ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 systems to detect criminal medication supply enterprises and alert relevant authorities
Wider context from the report “3. There is evidence that banks form a legitimate part of the supply chain, and that this is crucial to the functioning of these criminal enterprises. I am concerned that the current system for detecting such criminal enterprises and alerting the relevant authorities is not effective .
” Open source report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Other departments and agencies are best placed to respond directly to the concerns because they fall within their respective areas.
Verbatim wording from the response “Having reviewed these concerns, it is my view that the other departments and 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. However, I would like to offer the following information from a Departmental perspective, regarding the safe use of online pharmacies.” Source location Response from DHSC
Open published response
Concerns raised 5 Lack of inpatient mental health beds View source Gap in services for people too high risk to be sent home but not meeting Mental Health Act detention criteria View source Delays in referral to the Assessment and Treatment Service View source Shortage of mental health beds suitable for Autistic patients and transgender patients requiring a mixed ward View source Unsuitability of the A&E environment as a holding place for people awaiting mental health beds View source See 2 more concerns
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Matthew Zak Sheldrick (Matty) · 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
Matthew Zak Sheldrick (Matty), who identified as non-binary, had a history of mental health difficulties and was admitted to A&E in crisis on 3 November 2022 after a previous 26-day wait for a psychiatric bed. After being assessed under the Mental Health Act and not detained, Matty left hospital and was found hanging in the hospital grounds. Concerns included shortages and long waits for mental health beds, the unsuitability of A&E for neurodivergent patients, gaps in services and discharge planning, and shortcomings in the mental health assessment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of inpatient mental health beds
Wider context from the report “1. There is a lack of inpatient beds leading to unacceptable wait times in A&E for those suffering with their mental health who are awaiting beds. In Matty’s case a bed was not found for them within a 26-day period.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Gap in services for people too high risk to be sent home but not meeting Mental Health Act detention criteria
Wider context from the report “4. There is a gap in services for those who do not meet the criteria for detention under the Mental Health Act but who are too high a risk to be sent home.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 referral to the Assessment and Treatment Service
Wider context from the report “5. There is a significant wait time for referral to the Assessment and Treatment Service. Therefore, any therapeutic input is delayed , and this results in repetitive attendances at A&E when in crisis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Shortage of mental health beds suitable for Autistic patients and transgender patients requiring a mixed ward
Wider context from the report “2. There being a national shortage of mental health beds in particular for Autistic patients and those who are transgender requiring a mixed 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 Unsuitability of the A&E environment as a holding place for people awaiting mental health beds
Wider context from the report “3. The unsuitability of the environment of A&E as a holding place for those in need of a mental health bed. The environment in A&E as a holding place is not conducive for those suffering with Autism and/or who are neurodiverse. The environment in A&E can exacerbate their mental health.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish statutory guidance requiring coordinated, safe discharge from mental health, learning disability and autism inpatient settings.
Verbatim wording from the response “It is also important that, when people are discharged, this happens in a way that considers their needs on discharge and any risks to their safety. To help support safe and timely discharge decisions, the Department published statutory guidance on Discharge from mental health inpatient settings in January 2024 and which is available at: Discharge from mental health inpatient settings - GOV.UK (www.gov.uk). This sets out how health and care systems should work together to support safe discharge from all mental health and learning disability and autism inpatient settings for children, young people and adults.” Source location Response from DHSC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commit £26 million in capital investment to open new mental health crisis centres.
Verbatim wording from the response “As announced in the Budget, we are committing £26 million in capital investment to open new mental health crisis centres, reducing pressure on busy A&E services and ensuring people have the support they need when they need it.” Source location Response from DHSC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local trusts and health systems are responsible for assessing and managing mental-health bed capacity and patient flow.
Verbatim wording from the response “I expect individual trusts and local health systems to effectively assess and manage bed capacity, the ‘flow’ of patients being discharged or moving to another setting.” Source location Response from DHSC
Open published response
13 Dec 2024 Timothy Robert DE BOOS · Prevention of Future Deaths report Suffolk
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Concerns raised 3 Lack of Mental Health Unit inpatient beds View source Failure to treat the views of experienced mental health professionals, patients and families as sufficient evidence in voluntary inpatient admission decisions View source Delays in Crisis Resolution and Home Treatment Team review for Mental Health Unit admission View source
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AI-generated summary
Timothy Robert DE BOOS · 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
Timothy Robert DE BOOS was declared deceased at his home in Ipswich on 6 February 2024 after a self-inflicted domestic fire, with the medical cause of death recorded as smoke inhalation and severe burns. The report raises concerns about the lack of available Mental Health Unit inpatient beds and about the admission process when the patient, family, and an experienced mental health professional considered voluntary admission necessary.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of Mental Health Unit inpatient beds
Wider context from the report “1. I am concerned of the continuing lack of Mental Health Unit inpatient beds in Suffolk, and more widely throughout England and Wales .
At the time of Tim’s mental health crisis on the 2ⁿᵈ February 2024, had the decision to admit him been possible, he still would not have been admitted as there were five other individuals in the queue before him also waiting for admission .
The lack of available beds is not a new problem , and I have previously issued two Regulation 28 Prevention of Future Death Reports in which a lack of inpatient Mental Health Unit beds have contributed to a death-
Nicola Rayner (died 10ᵗʰ June 2023), reported 7ᵗʰ March 2024.
Piotr Kierzkowski (died 17ᵗʰ December 2019), reported 12ᵗʰ October 2020.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 treat the views of experienced mental health professionals, patients and families as sufficient evidence in voluntary inpatient admission decisions
Wider context from the report “2. In Tim’s case, on the 2ⁿᵈ of February 2024 Tim’s family, Tim himself, and Tim’s Mental Health Care Coordinator (a Senior Mental Health Nurse who had been supporting Tim for a year), all wished for his admission to a Mental Health Unit as a voluntary patient.
It was heard in evidence that a different team (the Crisis Resolution and Home Treatment Team) were the ‘gatekeepers’ for admission and this team could not review Tim until the next day.
When reviewed by Crisis Resolution and Home Treatment Team staff (who had never met Tim before), they believed his crisis had subsided and his admission was denied.
In evidence Tim’s Mental Health Care Coordinator was adamant that Tim should have been hospitalised on the 2ⁿᵈ February, as both his family and Tim himself had also wished.
I am therefore concerned that the views of an experienced mental health professional, a patient’s family, and the patient themselves, is deemed insufficient evidence for an admission to a Mental Health Unit as a voluntary inpatient .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 Crisis Resolution and Home Treatment Team review for Mental Health Unit admission
Wider context from the report “2. In Tim’s case, on the 2ⁿᵈ of February 2024 Tim’s family, Tim himself, and Tim’s Mental Health Care Coordinator (a Senior Mental Health Nurse who had been supporting Tim for a year), all wished for his admission to a Mental Health Unit as a voluntary patient.
It was heard in evidence that a different team (the Crisis Resolution and Home Treatment Team) were the ‘gatekeepers’ for admission and this team could not review Tim until the next day .
When reviewed by Crisis Resolution and Home Treatment Team staff (who had never met Tim before), they believed his crisis had subsided and his admission was denied.
In evidence Tim’s Mental Health Care Coordinator was adamant that Tim should have been hospitalised on the 2ⁿᵈ February, as both his family and Tim himself had also wished.
I am therefore concerned that the views of an experienced mental health professional, a patient’s family, and the patient themselves, is deemed insufficient evidence for an admission to a Mental Health Unit as a voluntary inpatient.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish statutory guidance on safe discharge from mental health inpatient settings.
Verbatim wording from the response “It is also important that when people are discharged, this happens in a way that considers their needs on discharge and any risks to their safety. To help support safe and timely discharge decisions, the Department published statutory guidance on Discharge from mental health inpatient settings in January 2024 and which is available at: Discharge from mental health inpatient settings - GOV.UK (www.gov.uk). This sets out how health and care systems should work together to support safe discharge from all mental health and learning disability and autism inpatient settings for children, young people and adults.” Source location Response from DHSC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Crisis Team remains responsible for inpatient assessments under national practice to ensure community alternatives are considered before admission.
Verbatim wording from the response “The Crisis Team remains the assessors for inpatient services in line with national practice. This is to ensure all opportunities for community interventions are explored because the evidence confirms this generally leads to better recovery outcomes. The community team made the referral to the Crisis Team on 2 February who then completed a visit on 3 and 4 February. The visits assessed that admission to hospital was no longer the immediate care need.” Source location Response from DHSC
Open published response
Concerns raised 3 Failure to ascertain relevant manager contact details for hospital helicopter landing sites View source Hazard to people on the ground near hospital helicopter landing sites View source Lack of a real-time database of hospital helicopter landing sites View source
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AI-generated summary
Jean LANGAN · 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 4 March 2022, Jean Langan fell and struck her head when the downwash from a landing helicopter affected her in a public car park at Derriford Hospital; she suffered a serious head injury and died shortly afterwards. The concerns identified included the safe landing of hospital helicopters without endangering people nearby, and the need for a real-time database of hospital helicopter landing sites and contact details for the relevant site managers.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ascertain relevant manager contact details for hospital helicopter landing sites
Wider context from the report “Helicopters should land safely at Hospital Helicopter Landing sites without endangering those on the ground in the vicinity of the landing site.
There was identified the need for a real time data base of Hospital Helicopter Landing sites to ensure the safe landing of helicopters.
There was identified a need to ascertain the contact details of the relevant manager of each Helicopter landing site at all Hospital Trusts which receive helicopters .
More particularly set out by the representative for the Air Service Operator by letter of the 6th of December 2024 reciting a request of 22 November 2024.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Hazard to people on the ground near hospital helicopter landing sites
Wider context from the report “Helicopters should land safely at Hospital Helicopter Landing sites without endangering those on the ground in the vicinity of the landing site .
There was identified the need for a real time data base of Hospital Helicopter Landing sites to ensure the safe landing of helicopters.
There was identified a need to ascertain the contact details of the relevant manager of each Helicopter landing site at all Hospital Trusts which receive helicopters.
More particularly set out by the representative for the Air Service Operator by letter of the 6th of December 2024 reciting a request of 22 November 2024.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a real-time database of hospital helicopter landing sites
Wider context from the report “Helicopters should land safely at Hospital Helicopter Landing sites without endangering those on the ground in the vicinity of the landing site.
There was identified the need for a real time data base of Hospital Helicopter Landing sites to ensure the safe landing of helicopters.
There was identified a need to ascertain the contact details of the relevant manager of each Helicopter landing site at all Hospital Trusts which receive helicopters.
More particularly set out by the representative for the Air Service Operator by letter of the 6th of December 2024 reciting a request of 22 November 2024.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage with NHS England and the Department for Transport to determine how to implement a fit-for-purpose real-time hospital helicopter landing-site database.
Verbatim wording from the response “DHSC has carefully considered your report and its recommendation to develop a database of HHLSs. We are engaging with NHS England and the Department of Transport to determine how best to implement this recommendation and ensure a database is fit for purpose. Turning to your recommendation to ensure each HHLS has an accountable manager, we agree a named accountable manager is essential for the safe running of HHLS and NHS England now have this information for all Trusts. As of the 31 January 2025 a named accountable manager has been identified and supplied, this is essential to the establishment and maintenance of an HHLS database.” Source location Response from DHSC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Identify and supply a named accountable manager for each NHS Trust hospital helicopter landing site.
Verbatim wording from the response “DHSC has carefully considered your report and its recommendation to develop a database of HHLSs. We are engaging with NHS England and the Department of Transport to determine how best to implement this recommendation and ensure a database is fit for purpose. Turning to your recommendation to ensure each HHLS has an accountable manager, we agree a named accountable manager is essential for the safe running of HHLS and NHS England now have this information for all Trusts. As of the 31 January 2025 a named accountable manager has been identified and supplied, this is essential to the establishment and maintenance of an HHLS database.” Source location Response from DHSC
Open published response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for ensuring hospital helicopter landing sites meet applicable CAP 1264 requirements.
Verbatim wording from the response “NHS England expects NHS trusts to follow the CAP1264 guidance. Through work they are undertaking to address the points set out above (and in Bristol’s letter of 6 December) NHS England will ensure that HHLS meet the CAP 1264 requirements, as appropriate.” Source location Response from DHSC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enforcement of hospital helicopter landing-site safety falls beyond DHSC’s limited role.
Verbatim wording from the response “We will learn from this tragic event and will take action to help mitigate the risk posed to members of the public, staff, and flight crew at hospital helicopter landing sites (HHLSs) across the UK. DHSC has a limited role in enforcing HHLS safety.” Source location Response from DHSC
Open published response
12 Dec 2024 James Robert Michael ALDERMAN · Prevention of Future Deaths report West London
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Concerns raised 3 Lack of guidance on breastfeeding young babies in carriers/slings View source Risk of suffocation for young babies in carriers/slings View source Lack of safety and positioning information for young babies in carriers/slings View source
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AI-generated summary
James Robert Michael ALDERMAN · 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
Jimmy was being breastfed in a baby carrier worn by his mother when he collapsed after five minutes. He died three days later in hospital from accidental suffocation after his airway was occluded while he was not held in a safe position. The report identified insufficient information and guidance for parents about safe positioning of young babies in carriers or slings, particularly when breastfeeding, and raised concerns about the need for industry safety standards.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on breastfeeding young babies in carriers/slings
Wider context from the report “(1) There is very little information available to inform parents of safety and positioning advice of young babies in carriers/slings and in particular nothing in relation to breastfeeding in carriers/slings
(2) This notwithstanding a significant increase over recent years in the use of such equipment.
(3) The question of whether it is safe to breastfeed "hands free" is not addressed or referred to in the public domain or manufacturers literature.
(4) The NHS available literature provides no guidance or advice.
(5) The only current "tips" are provided on the National Childbirth Trust (NCT) website but these are in fact unhelpful
(6) Young babies are at risk of suffocation.
(7) Consideration should be given to industry standards to promote the safe use of slings/carriers, to warn users of the risks and whether any such standards should be voluntary or mandatory.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Risk of suffocation for young babies in carriers/slings
Wider context from the report “(1) There is very little information available to inform parents of safety and positioning advice of young babies in carriers/slings and in particular nothing in relation to breastfeeding in carriers/slings
(2) This notwithstanding a significant increase over recent years in the use of such equipment.
(3) The question of whether it is safe to breastfeed "hands free" is not addressed or referred to in the public domain or manufacturers literature.
(4) The NHS available literature provides no guidance or advice.
(5) The only current "tips" are provided on the National Childbirth Trust (NCT) website but these are in fact unhelpful
(6) Young babies are at risk of suffocation.
(7) Consideration should be given to industry standards to promote the safe use of slings/carriers, to warn users of the risks and whether any such standards should be voluntary or mandatory.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 safety and positioning information for young babies in carriers/slings
Wider context from the report “(1) There is very little information available to inform parents of safety and positioning advice of young babies in carriers/slings and in particular nothing in relation to breastfeeding in carriers/slings
(2) This notwithstanding a significant increase over recent years in the use of such equipment.
(3) The question of whether it is safe to breastfeed "hands free" is not addressed or referred to in the public domain or manufacturers literature.
(4) The NHS available literature provides no guidance or advice.
(5) The only current "tips" are provided on the National Childbirth Trust (NCT) website but these are in fact unhelpful
(6) Young babies are at risk of suffocation.
(7) Consideration should be given to industry standards to promote the safe use of slings/carriers, to warn users of the risks and whether any such standards should be voluntary or mandatory.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with NHS England to establish consistent guidance on sling use and breastfeeding.
Verbatim wording from the response “Better Health – Start for Life already includes information about the safe use of baby carriers on its website and in personalised e-mails to parents. In response to your concerns, we are reviewing the information to ensure it is sufficiently prominent. We are also considering ways to supplement the content and engaging with key stakeholders, such as UNICEF UK, to make sure we get the messaging right about the use of baby carriers and breastfeeding. We will also work with NHS England to ensure there is consistent guidance on the use of slings and breastfeeding.” Source location Response from DHSC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage key stakeholders, including UNICEF UK, to develop appropriate messaging about baby carriers and breastfeeding.
Verbatim wording from the response “Better Health – Start for Life already includes information about the safe use of baby carriers on its website and in personalised e-mails to parents. In response to your concerns, we are reviewing the information to ensure it is sufficiently prominent. We are also considering ways to supplement the content and engaging with key stakeholders, such as UNICEF UK, to make sure we get the messaging right about the use of baby carriers and breastfeeding. We will also work with NHS England to ensure there is consistent guidance on the use of slings and breastfeeding.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider ways to supplement Better Health – Start for Life content about baby carriers and breastfeeding.
Verbatim wording from the response “Better Health – Start for Life already includes information about the safe use of baby carriers on its website and in personalised e-mails to parents. In response to your concerns, we are reviewing the information to ensure it is sufficiently prominent. We are also considering ways to supplement the content and engaging with key stakeholders, such as UNICEF UK, to make sure we get the messaging right about the use of baby carriers and breastfeeding. We will also work with NHS England to ensure there is consistent guidance on the use of slings and breastfeeding.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the prominence of existing baby-carrier safety information on the Better Health – Start for Life website and in personalised emails.
Verbatim wording from the response “Better Health – Start for Life already includes information about the safe use of baby carriers on its website and in personalised e-mails to parents. In response to your concerns, we are reviewing the information to ensure it is sufficiently prominent. We are also considering ways to supplement the content and engaging with key stakeholders, such as UNICEF UK, to make sure we get the messaging right about the use of baby carriers and breastfeeding. We will also work with NHS England to ensure there is consistent guidance on the use of slings and breastfeeding.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Baby sling manufacturers are responsible for providing clear guidance on product suitability and safe use during breastfeeding.
Verbatim wording from the response “Baby wearing or the use of baby slings may facilitate breastfeeding by helping mother and baby to stay close together. It is the responsibility of baby sling manufacturers to provide clear guidance on the use of their product, including suitability of the product to support breastfeeding and how this can be safely achieved.” Source location Response from DHSC
Open published response
Concerns raised 3 Inadequate social and community care provision View source Reliance on extreme mitigating measures instead of emergency ambulance provision View source Extreme operational pressure causing unallocated 999 calls and excessive ambulance delays View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
CHARLES GEORGE EDWARD DEVOS · 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
Charles George Edward Devos died at home on 9 January 2021 from an acute bowel condition after delayed clinical assessment following two 999 calls. The inquest found that the delay was a missed opportunity for potentially lifesaving treatment amid extreme operational pressure on ambulance services. The principal concerns were unallocated 999 calls, excessive ambulance delays, and reliance on measures such as self-conveyance, taxis and unattended emergency department drop-offs.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate social and community care provision
Wider context from the report “(1) Extreme operational pressure on ambulance services leading to volumes of unallocated 999 calls and excessive ambulance delays. There is a direct connection between the extreme operational pressure on SWAST and inadequate social and community care provision . This is because the inadequacy in these services creates a risk of future systemic failures causing excessive volumes of unallocated 999 calls and ambulance delays.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Reliance on extreme mitigating measures instead of emergency ambulance provision
Wider context from the report “(2) Ambulance call handlers and clinical advisors are being forced to resort to extreme mitigating measures to try and manage risks created by the systemic failures. These measures are being relied on in circumstances where ordinarily an emergency ambulance would be provided . The mitigating measures include resorting to recommending self-conveyance, arranging taxis and unattended drop offs at ED .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Extreme operational pressure causing unallocated 999 calls and excessive ambulance delays
Wider context from the report “(1) Extreme operational pressure on ambulance services leading to volumes of unallocated 999 calls and excessive ambulance delays . There is a direct connection between the extreme operational pressure on SWAST and inadequate social and community care provision. This is because the inadequacy in these services creates a risk of future systemic failures causing excessive volumes of unallocated 999 calls and ambulance delays.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement urgent and emergency care improvements identified through winter learning before the following winter.
Verbatim wording from the response “The 10 Year Health Plan will focus on ensuring three big reform shifts in the way our health services deliver care. First, from ‘hospital to community’ to bring care closer to where people live. Second, from ‘analogue to digital’ with new technologies and digital approaches to modernise the NHS, and third from ‘sickness to prevention’ so people spend less time with ill-health by preventing illnesses before they happen. The reforms will support putting the NHS on a sustainable footing for the future. In the shorter-term, by this Spring we will also set out the lessons learned from this winter and the improvements that we will put in place to improve urgent and emergency care ahead of next winter.” Source location Response from DHSC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch an independent commission into adult social care to inform development of a National Care Service.
Verbatim wording from the response “Turning to the concerns raised about social care, the Government is launching an independent commission into adult social care as part of our critical first steps towards delivering a National Care Service. The Commission, which is expected to begin in April” Source location Response from DHSC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Set out lessons learned from winter and planned urgent and emergency care improvements before the following winter.
Verbatim wording from the response “The 10 Year Health Plan will focus on ensuring three big reform shifts in the way our health services deliver care. First, from ‘hospital to community’ to bring care closer to where people live. Second, from ‘analogue to digital’ with new technologies and digital approaches to modernise the NHS, and third from ‘sickness to prevention’ so people spend less time with ill-health by preventing illnesses before they happen. The reforms will support putting the NHS on a sustainable footing for the future. In the shorter-term, by this Spring we will also set out the lessons learned from this winter and the improvements that we will put in place to improve urgent and emergency care ahead of next winter.” Source location Response from DHSC
Open published response
Concerns raised 1 Lack of sufficient theatre capacity to accommodate emergency and elective surgical demand 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
Karen Pamela DACK · 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
Karen Pamela Dack had worsening bowel stricture and obstruction, and planned surgery was delayed or cancelled on several occasions. Her bowel subsequently perforated, she developed sepsis and died despite further operations. The principal concern was the repeated cancellation of surgery because of limited theatre availability and the risk that similar delays could lead to further deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficient theatre capacity to accommodate emergency and elective surgical demand
Wider context from the report “That this lady’s surgery was cancelled at the last minute on three separate occasions due to lack of theatre availability . I heard from the Deputy Clinical Director at Leicester Royal Infirmary that there has been a review of how patients are prioritised and whether they are effectively using their emergency theatre capacity. He said that ‘the obvious problem with emergencies is they are unpredictable, there are times when the emergency list only requires one theatre and there are times when there are so many cases on the emergency list that we need to cancel elective cases in order to accommodate them and SOPs are in place around this.’ He went on to say that there were no imminent plans for theatre expansion at the University Hospitals of Leicester (UHL) and that the categorisation and access to emergency theatres are probably as good as they can get with the currently available resources.
I am concerned that whilst UHL is doing its utmost to deal with this problem the fact is that regardless of how patients are categorised there are still the same number of theatres available and that this issue will happen again, and further deaths may occur .
” Open source report
5 Dec 2024 Mazeedat Adeoye · Prevention of Future Deaths report East London
View report summary
Concerns raised 8 Inadequate supervision of social workers View source Failure to properly record the rationale for critical NRPF decisions View source Failure to communicate observed heat signatures during searches View source Culture tolerating unprofessional and antagonistic behaviour towards vulnerable people View source Failure to oversee arbitrary decisions made by junior staff View source Failure to periodically review social workers’ caseloads View source Failure to constrain inappropriate behaviour within the NRPF team View source Failure to appropriately assess heat signatures during searches 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
Mazeedat Adeoye · 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
Mazeedat Adeoye, a two-year-old girl, drowned on 29 January 2022 after falling into a water-filled plastic refuse bin while playing alone and inadequately supervised in a volunteer carer’s garden. The report identifies concerns about failures by local authority child services to arrange appropriate temporary care, as well as concerns regarding police search procedures, social-worker conduct and supervision, and inadequate record-keeping.
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 Inadequate supervision of social workers
Wider context from the report “3. The NRPF team was poorly managed. Social workers were not adequately supervised , and their caseloads were not periodically reviewed. The absence of leadership allowed a gradual erosion of empathy for the very people the team were employed to support. The absence of proper management left inappropriate behaviour unconstrained and allowed irrational decisions made arbitrarily by junior staff, to stand unchecked.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to properly record the rationale for critical NRPF decisions
Wider context from the report “4. Inadequate standards of note-keeping meant that the rationale for critical decisions made by the NRPF were not properly recorded . The absence of clear records diminished both communication within the team and accountability.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate observed heat signatures during searches
Wider context from the report “1. NPAS helicopter resources were utilised in the search for Mazeedat on 29th January 2022. At 16.40, a small circular heat signature was observed by a tactical flight officer within the garden where Mazeedat’s body was ultimately located. The shape and size of the object meant that the object was “discounted” in the search and its presence was not communicated to anyone . Mazeedat was discovered 11 minutes later by a police dog unit on the ground. Whereas the delay in locating Mazeedat did not contribute to her tragic death, the decision to discount such a heat signature could, in another case, amount to a risk of fatal harm.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Culture tolerating unprofessional and antagonistic behaviour towards vulnerable people
Wider context from the report “2. The Adeoye family interactions with the local authority, child services team were characterised by unprofessional behaviour from social workers . A culture existed within the team that tolerated and therefore encouraged overtly antagonistic behaviour towards vulnerable people . Should this hostile environment continue to be enabled, sub-optimal care outcomes will result with an ongoing risk of fatal harm.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to oversee arbitrary decisions made by junior staff
Wider context from the report “3. The NRPF team was poorly managed. Social workers were not adequately supervised, and their caseloads were not periodically reviewed. The absence of leadership allowed a gradual erosion of empathy for the very people the team were employed to support. The absence of proper management left inappropriate behaviour unconstrained and allowed irrational decisions made arbitrarily by junior staff, to stand unchecked .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 periodically review social workers’ caseloads
Wider context from the report “3. The NRPF team was poorly managed. Social workers were not adequately supervised, and their caseloads were not periodically reviewed . The absence of leadership allowed a gradual erosion of empathy for the very people the team were employed to support. The absence of proper management left inappropriate behaviour unconstrained and allowed irrational decisions made arbitrarily by junior staff, to stand unchecked.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 constrain inappropriate behaviour within the NRPF team
Wider context from the report “3. The NRPF team was poorly managed. Social workers were not adequately supervised, and their caseloads were not periodically reviewed. The absence of leadership allowed a gradual erosion of empathy for the very people the team were employed to support. The absence of proper management left inappropriate behaviour unconstrained and allowed irrational decisions made arbitrarily by junior staff, to stand unchecked.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 appropriately assess heat signatures during searches
Wider context from the report “1. NPAS helicopter resources were utilised in the search for Mazeedat on 29th January 2022. At 16.40, a small circular heat signature was observed by a tactical flight officer within the garden where Mazeedat’s body was ultimately located. The shape and size of the object meant that the object was “discounted” in the search and its presence was not communicated to anyone. Mazeedat was discovered 11 minutes later by a police dog unit on the ground. Whereas the delay in locating Mazeedat did not contribute to her tragic death, the decision to discount such a heat signature could, in another case, amount to a risk of fatal harm.
” 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 Department for Education is responsible for responding to concerns about child social care and is best placed to provide a formal response.
Verbatim wording from the response “The report raises concerns over the local authority and child services team in the London Borough of Newham. The Department of Education (DfE) has oversight for child social care, and they are best placed to comment on the concerns raised. You may wish to reissue the report to DfE, so they are able to provide a formal response.” Source location Response from DHSC
Open published response
Concerns raised 2 Unavailability of essential patient information to treating clinicians in new clinical settings View source Non-uniform hospital discharge notes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Patricia CURTIS · 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
Patricia Curtis underwent complex cardiac surgery and was transferred to Bedford Hospital, where she deteriorated rapidly and died from a haemothorax identified at post-mortem examination. The report states that a haemothorax was not included in the differential diagnosis when clinical signs first appeared. It also raises concern that non-uniform hospital discharge notes may result in essential information being unavailable after transfer between hospitals, potentially delaying life-saving care and treatment.
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 essential patient information to treating clinicians in new clinical settings
Wider context from the report “Hospital Discharge notes are not uniform across Hospital Trusts. This carries the risk of essential patient information not being available to treating clinicians when a patient is received into a new clinical setting , leading to potential delay in providing life saving care and 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 Non-uniform hospital discharge notes
Wider context from the report “Hospital Discharge notes are not uniform across Hospital Trusts. This carries the risk of essential patient information not being available to treating clinicians when a patient is received into a new clinical setting, leading to potential delay in providing life saving care and treatment.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish national statutory hospital discharge guidance requiring safe, timely discharge and accurate information sharing across organisational boundaries.
Verbatim wording from the response “While individual trusts are responsible for their own discharge policies, national statutory hospital discharge guidance has been published (last updated January 2024) which details the national discharge requirements for all NHS Trusts, commissioning bodies, local” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for individual hospital discharge policies lies with individual NHS trusts.
Verbatim wording from the response “In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. Individual trusts are responsible for their own discharge policies. I am therefore grateful to NHS England for advising that, since the report, they have engaged with Royal Papworth Hospital NHS Foundation Trust. I welcome the steps taken by the trust’s Discharge Planning Group around involvement of next of kin in patient transfers. I look forward to engaging with NHS England to understand how this develops.” Source location Response from DHSC
Open published response
2 Dec 2024 Junior George Powell · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 2 Delays in medical assessment and diagnosis of conditions requiring urgent treatment View source Lack of suitable community social care delaying discharge of patients ready to leave hospital 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
Junior George Powell · 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
Junior George Powell presented with acute abdominal pain and vomiting, was found to have an aortic dissection with reduced blood flow and intestinal ischaemia, and died at St George’s Hospital on 6 September 2021 after his condition deteriorated. The report identified concern that delays in discharging patients awaiting suitable social care can congest hospital admissions, delay assessment and diagnosis of urgent conditions, and increase the likelihood of death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in medical assessment and diagnosis of conditions requiring urgent treatment
Wider context from the report “That delay in discharge for patients ready to be discharged due to lack of suitable social care in the community is causing congestion in the hospital admission process, delaying medical assessment and thus diagnosis of conditions that need urgent treatment and increasing the likelihood of death for such 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 suitable community social care delaying discharge of patients ready to leave hospital
Wider context from the report “That delay in discharge for patients ready to be discharged due to lack of suitable social care in the community is causing congestion in the hospital admission process, delaying medical assessment and thus diagnosis of conditions that need urgent treatment and increasing the likelihood of death for such patients.
” Open source report
26 Nov 2024 Amy Jade BUTCHER · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 4 Lack of clinical knowledge about microdosing hallucinogenic mushrooms and its relevance to Lorazepam prescribing View source Lack of a clear prescribing decision-making and coordination system for mental health medication View source Unavailability of out-of-hours prescribing of Lorazepam when clinically required View source Failure to make an appropriate medication-concordance assessment when patients use alternative medication because PRN medication is ineffective 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
Amy Jade BUTCHER · 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
Amy Jade Butcher was declared deceased on 14 May 2023 after suspending herself with a ligature around her neck during a heightened anxiety crisis. The inquest identified concerns about a confusing, fragmented system for prescribing mental health medication, and about the decision not to prescribe Lorazepam despite its previous effectiveness for Amy.
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 knowledge about microdosing hallucinogenic mushrooms and its relevance to Lorazepam prescribing
Wider context from the report “Evidence was heard that a decision had been made by the Mental Health Multi-Disciplinary Team that Lorazepam was not to be prescribed to Amy in any event. The court heard that Lorazepam was highly addictive and the subject of frequent misuse by individuals to whom it was prescribed.
There were two reasons given for the MDT decision.
Firstly, Amy had volunteered to the Mental Health Team, that she had previously purchased online a ‘micro dose of hallucinogenic mushrooms’ to try and alleviate her systems. The court heard that like ‘homeopathic medication’ only a tiny amount of the active hallucinogen found in mushrooms would have been present, but that it was still illegal to possess this in the UK. Amy had told the team that she had only used this once.
The MDT decision was that because this was an illegal drug, because the MDT were unaware that micro dosing of hallucinogenic mushrooms was being used by mental health patients, and because they did not know how it would react with the Lorazepam, no Lorazepam was to be prescribed to Amy.
Secondly, Amy had previously disposed of medications prescribed to her which made her feel worse (a known side effect of some medications in the first few days of taking them). When advised to restart them, repeat prescriptions had to be made.
In addition, just prior to her death Amy volunteered that she had been taking a sleeping tablet (Zopiclone) in the mornings, as well as taking them when she was supposed to at night. Amy had said that her current PRN medication had no effect, but the Zopiclone did help.
As a result, it was recorded by the MDT that Amy was ‘non-concordant’ with her medication regime, therefore making her a higher risk of prescription misuse.
However, in her evidence, the Emergency Department Consultant said she was fully aware of the fact that micro dosing of hallucinogenic mushrooms was being used by mental health patients, and that due to the tiny amount of active hallucinogen it was generally not a barrier to the prescription of any other medication. In addition, the Emergency Department Consultant stated that if an individual had ingested a toxic quantity of hallucinogenic mushrooms, there was no contra-indication for the prescription of Lorazepam as it was often prescribed to reduce the hallucinogenic effects.
In the evidence heard from members of the MDT, it was clear that the illegal use of a ‘micro dose of hallucinogenic mushrooms’ coupled with Amy’s non-concordance, led to the decision not to prescribe her Lorazepam.
As such, a lack of knowledge in relation to the common usage of micro dose hallucinogenic mushrooms as a self-treatment by mental health patients , a lack of knowledge in relation to there being no contra-indications for prescription of Lorazepam if micro dose hallucinogenic mushrooms were being used , and defining Amy as ‘non-concordant’ due to her use of Zopiclone when her PRN medication proved ineffective, prevented a realistic opportunity for the MDT to consider if Lorazepam should have been prescribed to Amy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 clear prescribing decision-making and coordination system for mental health medication
Wider context from the report “Evidence heard at inquest identified a muddled and unclear system for the prescription of medication to someone in Amy’s situation.
The Emergency Department Consultant who saw Amy in crisis on the 10ᵗʰ May 2024 stated that for patients like Amy she had previously prescribed Lorazepam upon discharge home, but could only do this if the Mental Health Team in the ED requested her to do so, which they did not do on this occasion.
The following day, Amy herself tried to obtain a prescription of Lorazepam by dialling NHS 111 Option 2 (Mental Health line). She spoke to a mental health practitioner who told her that NHS 111 Option 2 did not have the ability to prescribe medication, and she would need to call NHS 111 Option 1 and speak to an Out of Hours GP instead.
Amy contacted NHS 111 Option 1 and spoke to an Out of Hours GP, who worked for a private company which had implemented a ban on the prescription of Lorazepam due to its highly addictive properties.
As such, even if the GP had considered Lorazepam to be required in Amy’s case, he could not have prescribed it. The GP prescribed different PRN medications, which were subsequently found in Amy’s system after her death.
Amy’s own GP gave evidence stating that the system for prescribing mental health medication was confusing . He stated that mental health medications prescribed to a patient by a GP (such as antidepressants) before a Mental Health Team became involved, remained the responsibility of the GP.
However, once a Mental Health Team became involved, any changes to the medication regime could only be made by the Mental Health Team.
In addition, some medication would be prescribed by the Mental Health Team directly, whilst other would be prescribed separately by the GP .
The GP described the situation as one of there simply being ‘too many chiefs’.
The net effect of the current system in place is that an individual in Amy’s situation finds themselves needing to make multiple telephone calls or contacts with NHS 111 Option 1, NHS 111 Option 2, their Out of Hours GP Service, their own GP and their Mental Health Team, in order to try and obtain either a new prescription or change their current prescription if their mental health suddenly deteriorates.
There is evidently no single point of contact, or single decision maker regarding prescriptions in these cases .
The evidence suggests that the situation is exacerbated even further if the individual’s mental health deterioration occurs Out of Hours.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of out-of-hours prescribing of Lorazepam when clinically required
Wider context from the report “Evidence heard at inquest identified a muddled and unclear system for the prescription of medication to someone in Amy’s situation.
The Emergency Department Consultant who saw Amy in crisis on the 10ᵗʰ May 2024 stated that for patients like Amy she had previously prescribed Lorazepam upon discharge home, but could only do this if the Mental Health Team in the ED requested her to do so, which they did not do on this occasion.
The following day, Amy herself tried to obtain a prescription of Lorazepam by dialling NHS 111 Option 2 (Mental Health line). She spoke to a mental health practitioner who told her that NHS 111 Option 2 did not have the ability to prescribe medication, and she would need to call NHS 111 Option 1 and speak to an Out of Hours GP instead.
Amy contacted NHS 111 Option 1 and spoke to an Out of Hours GP, who worked for a private company which had implemented a ban on the prescription of Lorazepam due to its highly addictive properties.
As such, even if the GP had considered Lorazepam to be required in Amy’s case, he could not have prescribed it . The GP prescribed different PRN medications, which were subsequently found in Amy’s system after her death.
Amy’s own GP gave evidence stating that the system for prescribing mental health medication was confusing. He stated that mental health medications prescribed to a patient by a GP (such as antidepressants) before a Mental Health Team became involved, remained the responsibility of the GP.
However, once a Mental Health Team became involved, any changes to the medication regime could only be made by the Mental Health Team.
In addition, some medication would be prescribed by the Mental Health Team directly, whilst other would be prescribed separately by the GP.
The GP described the situation as one of there simply being ‘too many chiefs’.
The net effect of the current system in place is that an individual in Amy’s situation finds themselves needing to make multiple telephone calls or contacts with NHS 111 Option 1, NHS 111 Option 2, their Out of Hours GP Service, their own GP and their Mental Health Team, in order to try and obtain either a new prescription or change their current prescription if their mental health suddenly deteriorates.
There is evidently no single point of contact, or single decision maker regarding prescriptions in these cases.
The evidence suggests that the situation is exacerbated even further if the individual’s mental health deterioration occurs Out of Hours .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to make an appropriate medication-concordance assessment when patients use alternative medication because PRN medication is ineffective
Wider context from the report “Evidence was heard that a decision had been made by the Mental Health Multi-Disciplinary Team that Lorazepam was not to be prescribed to Amy in any event. The court heard that Lorazepam was highly addictive and the subject of frequent misuse by individuals to whom it was prescribed.
There were two reasons given for the MDT decision.
Firstly, Amy had volunteered to the Mental Health Team, that she had previously purchased online a ‘micro dose of hallucinogenic mushrooms’ to try and alleviate her systems. The court heard that like ‘homeopathic medication’ only a tiny amount of the active hallucinogen found in mushrooms would have been present, but that it was still illegal to possess this in the UK. Amy had told the team that she had only used this once.
The MDT decision was that because this was an illegal drug, because the MDT were unaware that micro dosing of hallucinogenic mushrooms was being used by mental health patients, and because they did not know how it would react with the Lorazepam, no Lorazepam was to be prescribed to Amy.
Secondly, Amy had previously disposed of medications prescribed to her which made her feel worse (a known side effect of some medications in the first few days of taking them). When advised to restart them, repeat prescriptions had to be made.
In addition, just prior to her death Amy volunteered that she had been taking a sleeping tablet (Zopiclone) in the mornings, as well as taking them when she was supposed to at night. Amy had said that her current PRN medication had no effect, but the Zopiclone did help.
As a result, it was recorded by the MDT that Amy was ‘non-concordant’ with her medication regime, therefore making her a higher risk of prescription misuse.
However, in her evidence, the Emergency Department Consultant said she was fully aware of the fact that micro dosing of hallucinogenic mushrooms was being used by mental health patients, and that due to the tiny amount of active hallucinogen it was generally not a barrier to the prescription of any other medication. In addition, the Emergency Department Consultant stated that if an individual had ingested a toxic quantity of hallucinogenic mushrooms, there was no contra-indication for the prescription of Lorazepam as it was often prescribed to reduce the hallucinogenic effects.
In the evidence heard from members of the MDT, it was clear that the illegal use of a ‘micro dose of hallucinogenic mushrooms’ coupled with Amy’s non-concordance, led to the decision not to prescribe her Lorazepam.
As such, a lack of knowledge in relation to the common usage of micro dose hallucinogenic mushrooms as a self-treatment by mental health patients, a lack of knowledge in relation to there being no contra-indications for prescription of Lorazepam if micro dose hallucinogenic mushrooms were being used, and defining Amy as ‘non-concordant’ due to her use of Zopiclone when her PRN medication proved ineffective , prevented a realistic opportunity for the MDT to consider if Lorazepam should have been prescribed to Amy.
” 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 NICE guidance is considered to address concerns about which medicines should and should not be prescribed in different circumstances.
Verbatim wording from the response “NICE have reviewed their guideline CG113 on the management of generalised anxiety disorder (GAD) and panic disorder in adults, against your report. They have concluded that the guideline addresses the concerns raised by this very sad case as it covers which medicines should, and should not, be prescribed for the treatment of GAF in different circumstances.” 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 NHS England cannot currently include medication prescribing in NHS 111 mental health crisis services because prescribing is not feasible, including where triage is outsourced.
Verbatim wording from the response “Further, in August 2024 NHS England announced the introduction of access to local ageappropriate crisis services via NHS 111 ‘select mental health option’ (see https://www.england.nhs.uk/2024/08/nhs-111-offering-crisis-mental-health-support-for-thefirst-time/). It is not currently feasible to include prescription of medication under this service. NHS England has therefore introduced a fail-safe system whereby patients with medication queries or requests are advised to select option 1 (prescribing) when calling NHS 111. This acknowledges that most open crisis services are unable to prescribe medication. This should make the process easier and much clearer for patients.” Source location Response from DHSC
Open published response
25 Nov 2024 Margaret Mary Feeney · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1 Lack of measures to prevent excess prescribing to patients at risk of overdose during longer bank holiday periods View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Margaret Mary Feeney · 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
Margaret Mary Feeney was found deceased at home after taking excess prescribed medication, with pneumonia also contributing to her death. The principal concern was that prescribing and pharmacy arrangements around longer bank holiday periods allowed excess medication to be supplied to a patient recognised as being at risk of overdose.
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 measures to prevent excess prescribing to patients at risk of overdose during longer bank holiday periods
Wider context from the report “I am concerned that measures are not in place at Macklin Street Surgery and Daynight pharmacy to prevent prescription of excess medication to patient’s recognised to be at risk of overdose, either intentional or unintentional , who are ordinarily issued shorter period repeat prescriptions to reduce those risks. This situation arises when early prescriptions are issued due to statutory holiday periods when most pharmacies are likely to be closed. I have been informed that measures have been introduced to prevent excess prescribing by taking account of single day bank holidays, but there are no measures relating to longer bank holiday periods (e.g. Easter) . With electronic patient record and data systems it seems a reasonable presumption that suitable solutions can be identified.
” 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 Prescribing and dispensing decisions are assigned to responsible clinicians and pharmacists, who must apply clinical judgement and may delay dispensing where concerns arise.
Verbatim wording from the response “You outlined in your report that Ms Feeney had a long history of being prescribed benzodiazepines and codeine and had become dependent on them. It is important to note that the decision to prescribe a particular drug is a clinical one and should be based on the patient’s medical needs. Decisions about what medicines to prescribe are made by the doctor or healthcare professional responsible for that part of the patient’s care and” 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 NHS England, through regional Controlled Drugs Accountable Officers, holds national oversight responsibility for safe controlled-drug management and use.
Verbatim wording from the response “At a national level NHS England has a clear responsibility in providing systems oversight for the management and use of controlled drugs, including benzodiazepines and opioids. NHS England’s Controlled Drugs Accountable Officers (CDAO¹) undertake this role within each geographical region across England. They provide assurance that all healthcare organisations, including pharmacies, adopt a safe practice for appropriate clinical use, prescribing, storage, destruction and monitoring of controlled drugs.” Source location Response from DHSC
Open published response
22 Nov 2024 Nicolette Elizabeth McCARTHY · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 3 Inadequacy of national guidance on smoking and section 17 leave View source Failure of the NHS smoke-free policy to reflect the safety requirements of mental health wards and patients seeking leave to smoke View source Poor supervision of patients smoking during short grounds leave View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nicolette Elizabeth McCARTHY · 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
Nicolette Elizabeth McCarthy was detained in a secure mental health unit after attempts to take her life and remained at risk of suicide. On 19 September 2023, she failed to return from a short period of leave and was not promptly treated as absent without leave; the inquest identified failures in systems and procedures intended to ensure her safety. The report raises concerns that smoke-free policies and unclear guidance may increase the risk of self-harm or suicide for mental health patients on unescorted leave.
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 Inadequacy of national guidance on smoking and section 17 leave
Wider context from the report “1) During the course of the inquest, I heard evidence from clinicians and staff at the Trust to the effect that the NHS England smoke free policy is placing mental health in patients at an increased risk from self-harm and suicide.
2) Although smoking cessation advice and treatment (e.g. gum, vapes etc.) are routinely offered to patients, the evidence was that many struggle to give up smoking on their admission to the ward, in part because the anxiety associated with stopping exacerbates their mental health symptoms. Staff also felt that forcing patients to stop smoking against their will (e.g. by prohibiting them from smoking while on leave) would have a negative effect on their sense of autonomy and wellbeing, which are important for recovery.
3) The Trust understand that they are bound by the Health Act 2006 and by NHS England policy not to permit or facilitate smoking on the ward or anywhere on the grounds of the hospital. This is taken seriously and is interpreted to mean that staff are prohibited from facilitating smoking, for example by granting leave for the purpose of smoking or by escorting patients to smoke outside on short periods of leave. Senior staff also believed that it would be contrary to NHS policy to permit smoking in a secure area, for example the enclosed ward garden. At the same time, it was acknowledged that patients would inevitably seek leave to smoke and that this could not be denied without a negative impact on their mental health.
4) The jury heard evidence that patients, like Mrs McCarthy, were routinely given 15-minute grounds leave for the purpose of smoking, a practice that is discouraged by the Trust. Clinical staff felt that the policy placed them in a difficult position, torn between the need to comply with the smoke free policy, while also supporting patient autonomy and keeping safe those patients who are at a higher risk of self-harm or suicide.
5) There is a further contradiction caused by the smoke free policy, in that patients are not permitted to smoke on the grounds, but are not supposed to leave the grounds during short periods of ‘grounds’ leave. The result is that patients would spend their 15-minute leave smoking by the side of the road on the edge of the ward grounds, which is a poorly supervised area, and staff would avoid asking them too closely where they were going and would avoid standing close to them, even when smoking themselves. This contributed to the circumstances that allowed Mrs McCarthy to slip away unnoticed and ultimately to take her own life.
6) I also heard evidence from senior staff that the national policy guidance intended to address smoking and s17 leave (e.g. the NICE guidance and CQC guidance) does not adequately resolve these contradictions .
7) I am concerned that the NHS smoke free policy, while clearly motivated by a genuine and pressing concern to protect life and promote health, may not be adequately tailored to reflect the safety requirements of mental health wards or the reality that some mental health patients will inevitably seek short periods of leave to smoke. Action may need to be taken at the national policy level to provide clearer guidance and/or review the law to reduce the risk of patients in mental health wards absconding while on unescorted grounds leave.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of the NHS smoke-free policy to reflect the safety requirements of mental health wards and patients seeking leave to smoke
Wider context from the report “1) During the course of the inquest, I heard evidence from clinicians and staff at the Trust to the effect that the NHS England smoke free policy is placing mental health in patients at an increased risk from self-harm and suicide .
2) Although smoking cessation advice and treatment (e.g. gum, vapes etc.) are routinely offered to patients, the evidence was that many struggle to give up smoking on their admission to the ward, in part because the anxiety associated with stopping exacerbates their mental health symptoms. Staff also felt that forcing patients to stop smoking against their will (e.g. by prohibiting them from smoking while on leave) would have a negative effect on their sense of autonomy and wellbeing, which are important for recovery.
3) The Trust understand that they are bound by the Health Act 2006 and by NHS England policy not to permit or facilitate smoking on the ward or anywhere on the grounds of the hospital. This is taken seriously and is interpreted to mean that staff are prohibited from facilitating smoking, for example by granting leave for the purpose of smoking or by escorting patients to smoke outside on short periods of leave. Senior staff also believed that it would be contrary to NHS policy to permit smoking in a secure area, for example the enclosed ward garden. At the same time, it was acknowledged that patients would inevitably seek leave to smoke and that this could not be denied without a negative impact on their mental health.
4) The jury heard evidence that patients, like Mrs McCarthy, were routinely given 15-minute grounds leave for the purpose of smoking, a practice that is discouraged by the Trust. Clinical staff felt that the policy placed them in a difficult position, torn between the need to comply with the smoke free policy, while also supporting patient autonomy and keeping safe those patients who are at a higher risk of self-harm or suicide.
5) There is a further contradiction caused by the smoke free policy, in that patients are not permitted to smoke on the grounds, but are not supposed to leave the grounds during short periods of ‘grounds’ leave. The result is that patients would spend their 15-minute leave smoking by the side of the road on the edge of the ward grounds, which is a poorly supervised area, and staff would avoid asking them too closely where they were going and would avoid standing close to them, even when smoking themselves. This contributed to the circumstances that allowed Mrs McCarthy to slip away unnoticed and ultimately to take her own life.
6) I also heard evidence from senior staff that the national policy guidance intended to address smoking and s17 leave (e.g. the NICE guidance and CQC guidance) does not adequately resolve these contradictions.
7) I am concerned that the NHS smoke free policy, while clearly motivated by a genuine and pressing concern to protect life and promote health, may not be adequately tailored to reflect the safety requirements of mental health wards or the reality that some mental health patients will inevitably seek short periods of leave to smoke . Action may need to be taken at the national policy level to provide clearer guidance and/or review the law to reduce the risk of patients in mental health wards absconding while on unescorted grounds leave.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor supervision of patients smoking during short grounds leave
Wider context from the report “1) During the course of the inquest, I heard evidence from clinicians and staff at the Trust to the effect that the NHS England smoke free policy is placing mental health in patients at an increased risk from self-harm and suicide.
2) Although smoking cessation advice and treatment (e.g. gum, vapes etc.) are routinely offered to patients, the evidence was that many struggle to give up smoking on their admission to the ward, in part because the anxiety associated with stopping exacerbates their mental health symptoms. Staff also felt that forcing patients to stop smoking against their will (e.g. by prohibiting them from smoking while on leave) would have a negative effect on their sense of autonomy and wellbeing, which are important for recovery.
3) The Trust understand that they are bound by the Health Act 2006 and by NHS England policy not to permit or facilitate smoking on the ward or anywhere on the grounds of the hospital. This is taken seriously and is interpreted to mean that staff are prohibited from facilitating smoking, for example by granting leave for the purpose of smoking or by escorting patients to smoke outside on short periods of leave. Senior staff also believed that it would be contrary to NHS policy to permit smoking in a secure area, for example the enclosed ward garden. At the same time, it was acknowledged that patients would inevitably seek leave to smoke and that this could not be denied without a negative impact on their mental health.
4) The jury heard evidence that patients, like Mrs McCarthy, were routinely given 15-minute grounds leave for the purpose of smoking, a practice that is discouraged by the Trust. Clinical staff felt that the policy placed them in a difficult position, torn between the need to comply with the smoke free policy, while also supporting patient autonomy and keeping safe those patients who are at a higher risk of self-harm or suicide.
5) There is a further contradiction caused by the smoke free policy, in that patients are not permitted to smoke on the grounds, but are not supposed to leave the grounds during short periods of ‘grounds’ leave. The result is that patients would spend their 15-minute leave smoking by the side of the road on the edge of the ward grounds, which is a poorly supervised area , and staff would avoid asking them too closely where they were going and would avoid standing close to them , even when smoking themselves. This contributed to the circumstances that allowed Mrs McCarthy to slip away unnoticed and ultimately to take her own life.
6) I also heard evidence from senior staff that the national policy guidance intended to address smoking and s17 leave (e.g. the NICE guidance and CQC guidance) does not adequately resolve these contradictions.
7) I am concerned that the NHS smoke free policy, while clearly motivated by a genuine and pressing concern to protect life and promote health, may not be adequately tailored to reflect the safety requirements of mental health wards or the reality that some mental health patients will inevitably seek short periods of leave to smoke. Action may need to be taken at the national policy level to provide clearer guidance and/or review the law to reduce the risk of patients in mental health wards absconding while on unescorted grounds leave.
” 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 Advance the Tobacco and Vapes Bill to expand smoke-free-place provisions, including potential outdoor spaces.
Verbatim wording from the response “You may also be aware that the Department is currently taking action to tackle the harms of second-hand smoking through the Tobacco and Vapes Bill which is currently making its way through Parliament. Part of the Bill provides ministers with powers to expand the current smoke-free places provisions in the Health Act 2006 to more public places and workplaces, including outdoor spaces. In England, we have announced our intention to make outside hospital grounds smoke-free. This will be subject to a consultative process and as part of this we will consider whether designated areas for smoking are appropriate.” 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 consultation on making hospital grounds smoke-free and consider whether designated smoking areas are appropriate.
Verbatim wording from the response “You may also be aware that the Department is currently taking action to tackle the harms of second-hand smoking through the Tobacco and Vapes Bill which is currently making its way through Parliament. Part of the Bill provides ministers with powers to expand the current smoke-free places provisions in the Health Act 2006 to more public places and workplaces, including outdoor spaces. In England, we have announced our intention to make outside hospital grounds smoke-free. This will be subject to a consultative process and as part of this we will consider whether designated areas for smoking are appropriate.” 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 legal and regulatory arrangements provide that Section 17 leave requires clinician authorisation and risk assessment and should not facilitate smoking breaks.
Verbatim wording from the response “Turning to your concerns regarding a lack of clarity around using Section 17 of the Mental Health Act 1983 to allow inpatients a short leave of absence in order to take a smoking break. Under Section 17 of the Act, a leave of absence can only be authorised by the patient’s responsible clinician and would require a risk assessment to be undertaken. The Care Quality Commission’s guidance: Smokefree policies in mental health inpatient services³ makes it clear that Section 17 should not be used to facilitate smoking breaks.” 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 NHS England is responsible for addressing concerns about national guidance and policy, while the NHS trust is addressing local issues.
Verbatim wording from the response “I understand that, in its response to your report, NHS England will address your concerns around national guidance and policy and is also engaging with the Sussex Partnership NHS Foundation Trust to provide information about the local issues you have raised.” 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 Research indicates that smoke-free policies do not exacerbate mental health symptoms, and trusts have implemented them with few unintended consequences.
Verbatim wording from the response “I understand the concerns raised in your report about whether a smoke-free policy covering hospital grounds may place mental health inpatients at an increased risk from self-harm and suicide. However, research carried out on smoking bans in psychiatric inpatient settings⁴ indicates that smoking cessation does not exacerbate mental health symptoms. I am also aware of a number of mental health trusts that have implemented smoke-free policies successfully, resulting in high rates of compliance and few unintended consequences.” Source location Response from DHSC
Open published response
15 Nov 2024 Yousef Al-Kharboush and 2 others · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Lack of requirements for section 10 exempt entities to report adverse-event findings to the MHRA and other relevant organisations View source Unclear thresholds for section 10 entity reporting to NHSE and the CQC View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Yousef Al-Kharboush and 2 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Aviva Otte died in January 2014 after receiving TPN provided and compounded by an NHS establishment; the TPN was, on balance, contaminated with Bacillus cereus. Oscar Barker and Yousef Al-Kharboush died in June 2014 after receiving TPN compounded by a commercial provider that was also contaminated with Bacillus cereus. The principal concerns were unclear or absent requirements for section 10 exempt entities to report adverse-event findings and uncertainty about reporting thresholds and wider dissemination of information that could help other providers assess risks.
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 requirements for section 10 exempt entities to report adverse-event findings to the MHRA and other relevant organisations
Wider context from the report “(1) There is no requirement for a section 10 exempt entity to report any of its findings to the MHRA or indeed to other Trusts or the industry in general if an adverse event occurs.
(2) The current reporting structures (for a section 10 entity) involve reporting to NHSE and the CQC but the threshold of necessity for such reporting appears unclear and, in essence, up to the Trust.
(3) There may be times when section 10 entities reach conclusions which would assist the wider industry and help to assist both other Trusts and commercial organisations in assessing their own risks and improving the provision of highly specific medication to a group of vulnerable patients.
(4) the same may also be true of commercial organisations but they have the power of the MHRA controlling and effecting recalls and actions and the wider dissemination of 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 Unclear thresholds for section 10 entity reporting to NHSE and the CQC
Wider context from the report “(1) There is no requirement for a section 10 exempt entity to report any of its findings to the MHRA or indeed to other Trusts or the industry in general if an adverse event occurs.
(2) The current reporting structures (for a section 10 entity) involve reporting to NHSE and the CQC but the threshold of necessity for such reporting appears unclear and, in essence, up to the Trust.
(3) There may be times when section 10 entities reach conclusions which would assist the wider industry and help to assist both other Trusts and commercial organisations in assessing their own risks and improving the provision of highly specific medication to a group of vulnerable patients.
(4) the same may also be true of commercial organisations but they have the power of the MHRA controlling and effecting recalls and actions and the wider dissemination of 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 NHS England, MHRA and CQC are responsible for implementing responses to the identified gaps; DHSC will coordinate their actions.
Verbatim wording from the response “However, the gap you identified has not been fully addressed by this and there is more work to do in this area. NHS England, MHRA and CQC will be sending their individual responses to the PFD report to set out how they will address the concerns raised. This includes:” Source location Response from DHSC
Open published response
14 Nov 2024 Hannah Mary AITKEN · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 6 Lack of active consideration of controls on public access to the substances View source Lack of central monitoring of poisoning incidents involving the substances View source Unrestricted domestic sale of the substances View source Lack of regulation and monitoring of use of the substances outside the Poisons Act 1972 View source Lack of consideration of controls on the quantities and purity in which the substances are sold View source Unrestricted import of the substances 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
Hannah Mary AITKEN · 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
Hannah Mary Aitken died at her supported accommodation on 14 September 2023 after taking an overdose of a poisonous substance obtained with the intention of ending her life. The report raises concerns about the unrestricted domestic and international availability of the substance, the quantities and purity in which it is sold, and the lack of central monitoring or clear responsibility for regulating its use in relation to self-harm.
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 active consideration of controls on public access to the substances
Wider context from the report “The Court heard anecdotal evidence from three Emergency Medical Consultants and others witnesses that in their direct experience, the use of ████████ for self-harm is increasing. However, none were aware of a central monitoring system which is able to record incidents of ████████ poisoning.
████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. There are no restrictions on the import of ████████ from abroad.
Since 2020, the Home Office has received at least five Prevention of Future Death Reports relating to ████████ The Home Secretary has recently provided reassurance in response to the Regulation 28 report relating to the death of Dr Jonathan Shaw that “the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and other similar substances)”.
The Home Office has clarified in evidence during this inquest that the policy objective of the Poisons Act 1972 is to control access to explosives precursors and poisons and to detect terrorist use of these substances to illicitly manufacture explosives or to cause harm to third parties. Prevention of suicide/self-harm is not a policy objective of the Home Office under this Act, and this falls under the remit of the Department for Health and Social Care. No evidence was provided that there is active consideration of controlling access to these substances to the general public, whether under the remit of the Home Office or any other Government department .
Whilst these substances have legitimate uses, including ████████ ████████ there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions;
████████
████████
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in ████████
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of central monitoring of poisoning incidents involving the substances
Wider context from the report “The Court heard anecdotal evidence from three Emergency Medical Consultants and others witnesses that in their direct experience, the use of ████████ for self-harm is increasing. However, none were aware of a central monitoring system which is able to record incidents of ████████ poisoning .
████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. There are no restrictions on the import of ████████ from abroad.
Since 2020, the Home Office has received at least five Prevention of Future Death Reports relating to ████████ The Home Secretary has recently provided reassurance in response to the Regulation 28 report relating to the death of Dr Jonathan Shaw that “the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and other similar substances)”.
The Home Office has clarified in evidence during this inquest that the policy objective of the Poisons Act 1972 is to control access to explosives precursors and poisons and to detect terrorist use of these substances to illicitly manufacture explosives or to cause harm to third parties. Prevention of suicide/self-harm is not a policy objective of the Home Office under this Act, and this falls under the remit of the Department for Health and Social Care. No evidence was provided that there is active consideration of controlling access to these substances to the general public, whether under the remit of the Home Office or any other Government department.
Whilst these substances have legitimate uses, including ████████ ████████ there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions;
████████
████████
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in ████████
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unrestricted domestic sale of the substances
Wider context from the report “The Court heard anecdotal evidence from three Emergency Medical Consultants and others witnesses that in their direct experience, the use of ████████ for self-harm is increasing. However, none were aware of a central monitoring system which is able to record incidents of ████████ poisoning.
████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. There are no restrictions on the import of ████████ from abroad.
Since 2020, the Home Office has received at least five Prevention of Future Death Reports relating to ████████ The Home Secretary has recently provided reassurance in response to the Regulation 28 report relating to the death of Dr Jonathan Shaw that “the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and other similar substances)”.
The Home Office has clarified in evidence during this inquest that the policy objective of the Poisons Act 1972 is to control access to explosives precursors and poisons and to detect terrorist use of these substances to illicitly manufacture explosives or to cause harm to third parties. Prevention of suicide/self-harm is not a policy objective of the Home Office under this Act, and this falls under the remit of the Department for Health and Social Care. No evidence was provided that there is active consideration of controlling access to these substances to the general public, whether under the remit of the Home Office or any other Government department.
Whilst these substances have legitimate uses, including ████████ ████████ there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions ;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions;
████████
████████
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in ████████
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of regulation and monitoring of use of the substances outside the Poisons Act 1972
Wider context from the report “The Court heard anecdotal evidence from three Emergency Medical Consultants and others witnesses that in their direct experience, the use of ████████ for self-harm is increasing. However, none were aware of a central monitoring system which is able to record incidents of ████████ poisoning.
████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. There are no restrictions on the import of ████████ from abroad.
Since 2020, the Home Office has received at least five Prevention of Future Death Reports relating to ████████ The Home Secretary has recently provided reassurance in response to the Regulation 28 report relating to the death of Dr Jonathan Shaw that “the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and other similar substances)”.
The Home Office has clarified in evidence during this inquest that the policy objective of the Poisons Act 1972 is to control access to explosives precursors and poisons and to detect terrorist use of these substances to illicitly manufacture explosives or to cause harm to third parties. Prevention of suicide/self-harm is not a policy objective of the Home Office under this Act, and this falls under the remit of the Department for Health and Social Care. No evidence was provided that there is active consideration of controlling access to these substances to the general public, whether under the remit of the Home Office or any other Government department.
Whilst these substances have legitimate uses, including ████████ ████████ there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions;
████████
████████
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in ████████
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972 , and it is not clear which Government department would be responsible for this .
Consideration should be given to whether any steps can be taken to address the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of consideration of controls on the quantities and purity in which the substances are sold
Wider context from the report “The Court heard anecdotal evidence from three Emergency Medical Consultants and others witnesses that in their direct experience, the use of ████████ for self-harm is increasing. However, none were aware of a central monitoring system which is able to record incidents of ████████ poisoning.
████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. There are no restrictions on the import of ████████ from abroad.
Since 2020, the Home Office has received at least five Prevention of Future Death Reports relating to ████████ The Home Secretary has recently provided reassurance in response to the Regulation 28 report relating to the death of Dr Jonathan Shaw that “the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and other similar substances)”.
The Home Office has clarified in evidence during this inquest that the policy objective of the Poisons Act 1972 is to control access to explosives precursors and poisons and to detect terrorist use of these substances to illicitly manufacture explosives or to cause harm to third parties. Prevention of suicide/self-harm is not a policy objective of the Home Office under this Act, and this falls under the remit of the Department for Health and Social Care. No evidence was provided that there is active consideration of controlling access to these substances to the general public, whether under the remit of the Home Office or any other Government department.
Whilst these substances have legitimate uses, including ████████ ████████ there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold , against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions;
████████
████████
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use , for example in ████████
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unrestricted import of the substances
Wider context from the report “The Court heard anecdotal evidence from three Emergency Medical Consultants and others witnesses that in their direct experience, the use of ████████ for self-harm is increasing. However, none were aware of a central monitoring system which is able to record incidents of ████████ poisoning.
████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. There are no restrictions on the import of ████████ from abroad .
Since 2020, the Home Office has received at least five Prevention of Future Death Reports relating to ████████ The Home Secretary has recently provided reassurance in response to the Regulation 28 report relating to the death of Dr Jonathan Shaw that “the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and other similar substances)”.
The Home Office has clarified in evidence during this inquest that the policy objective of the Poisons Act 1972 is to control access to explosives precursors and poisons and to detect terrorist use of these substances to illicitly manufacture explosives or to cause harm to third parties. Prevention of suicide/self-harm is not a policy objective of the Home Office under this Act, and this falls under the remit of the Department for Health and Social Care. No evidence was provided that there is active consideration of controlling access to these substances to the general public, whether under the remit of the Home Office or any other Government department.
Whilst these substances have legitimate uses, including ████████ ████████ there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions ;
████████
████████
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in ████████
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this.
Consideration should be given to whether any steps can be taken to address the above concerns.
” 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 the Home Office to convene departments and agencies and identify whether further regulation is appropriate and which body should review it.
Verbatim wording from the response “On the issue of further regulation, the Department is working closely with the Home Office to convene Government departments and agencies to identify whether regulation is appropriate and would achieve the intended aim, and if so which body is best placed to take forward any reviews into this.” 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 operational work with organisations to reduce access to concerning methods.
Verbatim wording from the response “The group has worked with businesses, including online suppliers and manufacturers of the substance, to reduce people’s ability to purchase it for non-legitimate purposes including suicide, and to raise awareness around safeguarding concerns with businesses where required. Government departments have also previously worked with manufacturers to reduce the lethality of the substance if ingested. This included work with online platforms to remove it from sale to individuals in its pure form. The group continues to work operationally with a range of organisations, and we are actively considering opportunities to work with the Border Force, using existing legal provisions, to help detect packages at the border which may be linked to vulnerable individuals and intended for suicide. The group’s actions are kept under review.” 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 with businesses, online suppliers and manufacturers to reduce non-legitimate purchasing and raise safeguarding awareness.
Verbatim wording from the response “The group has worked with businesses, including online suppliers and manufacturers of the substance, to reduce people’s ability to purchase it for non-legitimate purposes including suicide, and to raise awareness around safeguarding concerns with businesses where required. Government departments have also previously worked with manufacturers to reduce the lethality of the substance if ingested. This included work with online platforms to remove it from sale to individuals in its pure form. The group continues to work operationally with a range of organisations, and we are actively considering opportunities to work with the Border Force, using existing legal provisions, to help detect packages at the border which may be linked to vulnerable individuals and intended for suicide. The group’s actions are kept under review.” 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 Monitor trends in the substance and other concerning methods using intelligence from multiple sources, including national statistics and local organisations.
Verbatim wording from the response “You also raised the issue of monitoring. The Department monitors trends of this substance and other concerning methods as part of the working group. We have approaches in place to collect intelligence from a wide range of sources. We use Office for National Statistics data, and we are exploring how to make better use of national near real time suspected suicide surveillance data to make sure we can identify and respond to trends more quickly. Regional Leads within the Office for Health Improvement and Disparities also pass on information from local organisations to central teams for monitoring. Whilst we observed an increase in the number of suicides using this method a few years ago, we have not found concrete evidence that the numbers have increased in the last few years, and since the Concerning Methods Working Group was set up.” 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 Consider working with Border Force, using existing legal provisions, to detect potentially suicide-related packages sent to vulnerable individuals.
Verbatim wording from the response “The group has worked with businesses, including online suppliers and manufacturers of the substance, to reduce people’s ability to purchase it for non-legitimate purposes including suicide, and to raise awareness around safeguarding concerns with businesses where required. Government departments have also previously worked with manufacturers to reduce the lethality of the substance if ingested. This included work with online platforms to remove it from sale to individuals in its pure form. The group continues to work operationally with a range of organisations, and we are actively considering opportunities to work with the Border Force, using existing legal provisions, to help detect packages at the border which may be linked to vulnerable individuals and intended for suicide. The group’s actions are kept under review.” 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 Operate the Concerning Methods Working Group to develop and deliver targeted actions reducing public access to emerging suicide methods.
Verbatim wording from the response “On methods of suicide specifically, Government departments have taken steps to reduce access to, and awareness of, this substance. DHSC leads a Concerning Methods Working Group to raise awareness of and tackle access to substances such as this one. The working group involves representatives from the voluntary, community and social enterprise sector, police, academics and the NHS, as well as Government departments including Department of Science, Innovation and Technology and the Home Office. The group develops and delivers rapid targeted actions to collectively reduce public access to emerging methods, including this one. Over 30 of the actions identified and implemented by the group have been to tackle this substance specifically.” 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 with online platforms to remove the substance from sale to individuals in its pure form.
Verbatim wording from the response “The group has worked with businesses, including online suppliers and manufacturers of the substance, to reduce people’s ability to purchase it for non-legitimate purposes including suicide, and to raise awareness around safeguarding concerns with businesses where required. Government departments have also previously worked with manufacturers to reduce the lethality of the substance if ingested. This included work with online platforms to remove it from sale to individuals in its pure form. The group continues to work operationally with a range of organisations, and we are actively considering opportunities to work with the Border Force, using existing legal provisions, to help detect packages at the border which may be linked to vulnerable individuals and intended for suicide. The group’s actions are kept under review.” Source location Response from DHSC
Open published response
12 Nov 2024 Lisa Gale · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure of urgent liver function test reporting thresholds to account for pregnancy-specific conditions View source Failure to communicate grossly abnormal liver function test results from laboratory staff to clinical staff 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
Lisa Gale · 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
Lisa Gale developed Acute Fatty Liver of Pregnancy (AFLP) and later died despite hospital treatment and intensive care. The report raises concerns that markedly abnormal liver-function results were not urgently communicated because reporting thresholds did not account for pregnancy-specific conditions, resulting in a delay in diagnosing AFLP and starting appropriate treatment.
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 urgent liver function test reporting thresholds to account for pregnancy-specific conditions
Wider context from the report “(1) Blood was taken for liver function tests (LFTs) on admission before her condition was diagnosed;
(2) Lisa’s LFT’s were grossly elevated (normal range in brackets) – ALT 612 (10-50), bilirubin 122 (<21), creatine 168 (45-84);
(3) This was due to a potentially fatal condition – Acute Fatty Liver of Pregnancy – from which she subsequently died;
(3) Despite being grossly elevated, the results once obtained in the laboratory were not phoned through by the laboratory staff to the clinical staff;
(4) This was because the Royal College of Pathologists’ guidelines for urgent reporting only provides for the same with levels above 750 for ALT, 300 for bilirubin and 354 for creatinine – and does not provide for different reporting levels for those taken in pregnant women ;
(5) This is despite pregnancy specific conditions such as AFLP being potentially fatal at much lower levels of abnormal LFTs than those set currently by the Royal College of Pathologists ;
(4) As a result there was a delay in diagnosing her AFLP and starting appropriate 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 Failure to communicate grossly abnormal liver function test results from laboratory staff to clinical staff
Wider context from the report “(1) Blood was taken for liver function tests (LFTs) on admission before her condition was diagnosed;
(2) Lisa’s LFT’s were grossly elevated (normal range in brackets) – ALT 612 (10-50), bilirubin 122 (<21), creatine 168 (45-84);
(3) This was due to a potentially fatal condition – Acute Fatty Liver of Pregnancy – from which she subsequently died;
(3) Despite being grossly elevated, the results once obtained in the laboratory were not phoned through by the laboratory staff to the clinical staff ;
(4) This was because the Royal College of Pathologists’ guidelines for urgent reporting only provides for the same with levels above 750 for ALT, 300 for bilirubin and 354 for creatinine – and does not provide for different reporting levels for those taken in pregnant women;
(5) This is despite pregnancy specific conditions such as AFLP being potentially fatal at much lower levels of abnormal LFTs than those set currently by the Royal College of Pathologists;
(4) As a result there was a delay in diagnosing her AFLP and starting appropriate treatment.
” Open source report
6 Nov 2024 Simon Boyd · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to adhere to national ambulance response-time targets View source Use of NHS Pathways call-handler script wording that misleadingly implies ambulance dispatch View source Cancellation of ambulance responses without discussion with callers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Simon Boyd · 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
Simon Boyd, who had reported dizziness, lethargy, sweating and later breathlessness, was found unresponsive at home on 1 June 2024 after an ambulance response was cancelled and a routine same-day home visit was arranged. Attempts to revive him were unsuccessful, and the inquest recorded myocardial infarction, coronary artery disease and hypertension. Concerns included ambulance response times not meeting national targets, potentially misleading NHS Pathways wording about ambulance dispatch, and cancellation of an ambulance response without first discussing this with the caller.
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 adhere to national ambulance response-time targets
Wider context from the report “1. The court heard evidence to the effect that, notwithstanding the national target for Category 3 99% calls of 9 out of 10 responses within 120 minutes, the anticipated wait for a Category 3 ambulance on 1st June 2024 was around 3 hours and 15 minutes. This is a factor which contributed to decision-making in this case.
I am concerned that national targets for ambulance response times continue not to be adhered to .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Use of NHS Pathways call-handler script wording that misleadingly implies ambulance dispatch
Wider context from the report “1. I am concerned that the current wording of some of the script used by Call Handlers under NHS Pathways creates an impression that an ambulance has been dispatched to a caller at a point when this is, in fact, not the case .
Phrases such as ‘An emergency ambulance has been arranged’, ‘we will be with you as soon as possible, as soon as an ambulance is available’ and ‘if you can ask for someone to meet and direct the vehicle and shut any dogs away if there are any’ potentially give a misleading impression as to ambulance dispatch having occurred , which could conceivably deter a caller from taking steps which might realistically result in them obtaining faster help.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Cancellation of ambulance responses without discussion with callers
Wider context from the report “2. A further matter of concern arises from the potential under the NHS Pathways paradigm for an ambulance response to be cancelled without this first being discussed with the person who has felt it necessary to dial 999 and request an ambulance in the first place .
” 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 Support the NHS, including ambulance services, to achieve safe operational response-time standards.
Verbatim wording from the response “This Government recognises that in recent years, ambulance response time performance has been below the high standards that patients should expect. That is why this Government has committed to supporting the National Health Service to improve performance, including ambulance services achieving the safe operational response times standards set out in the NHS Constitution.” 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 NHS England is responsible for addressing concerns about the NHS Pathways script wording used by call handlers.
Verbatim wording from the response “Your report raises concerns about ambulance response times and the script used by call handlers. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. I understand NHS England are writing to you regarding the specific concerns you have raised on the current wording used in the NHS Pathways script by call handlers.” Source location Response from DHSC
Open published response
4 Nov 2024 JAGJEET SINGH · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Lack of sufficient mental health bed capacity View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
JAGJEET SINGH · 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
Jagjeet Singh, who had a history of intravenous substance misuse and mental and physical health problems, injected heroin after leaving hospital and was found deceased the following day with a syringe nearby. The inquest concluded that the death was drug related, with acute respiratory depression and fatal morphine and methadone toxicity identified as causes. The report raised concerns about the lack of an available mental health bed after medical-ward admissions, resulting in temporary accommodation, eviction and at least one night sleeping rough.
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 sufficient mental health bed capacity
Wider context from the report “Mr Singh was an inpatient on a mental health ward at the Homerton Hospital from 20 August 2023 until 6 March 2024, initially under s.2 of the Mental Health Act and then as an informal patient. On three occasions he spent time on medical wards for infected leg ulcers, arising from his IV drug use. During these periods his mental health bed was, understandably, allocated to other patients. However, on discharge from the medical ward, there was no mental health bed available for him and he either went home or, as his property was uninhabitable for a period of time, was accommodated in a Travel Lodge at the cost of the Trust, returning to the mental health ward for meals and medication. Mr Singh did not like the Travel Lodge and on one occasion was evicted. He therefore slept on a coach in the mental health ward and appears to have spent at least one night sleeping rough.
I heard that a bed on the mental health ward should have been available for Mr Singh when he was discharged from the medical wards but that there is a chronic shortage of mental health beds and not just in London but nationally . It was described to me as a crisis .
” 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 statutory guidance supporting safe discharge from mental health and learning disability and autism inpatient settings.
Verbatim wording from the response “It is also important that when people are discharged, this happens in a way that considers their needs on discharge and any risks to their safety. To help support safe and timely discharge decisions, the Department published statutory guidance on Discharge from mental health inpatient settings in January 2024 and which is available at: Discharge from mental health inpatient settings - GOV.UK (www.gov.uk). This sets out how health and care systems should work together to support safe discharge from all mental health and learning disability and autism inpatient settings for children, young people and adults.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand delivery of mental health care in community settings through new models of care and support.
Verbatim wording from the response “As part of our mission to build an NHS fit for the future, we will make sure more mental health care is delivered in the community, close to people’s homes, through new models of care and support, so that fewer people need to go into hospital.” 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 NHS England is responsible for addressing the reported concerns about mental health bed availability.
Verbatim wording from the response “I understand your concerns about a bed on the mental health ward not being available for Mr Singh when he was discharged from the medical wards. I note that you have also addressed these matters of concern to the Chief Executive of NHS England. I look forward to seeing her response and working with NHS England where appropriate, to avoid a repetition of the tragic events of this case.” 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 Individual trusts and local health systems are responsible for assessing and managing mental health bed capacity, patient flow and specialist rehabilitation availability.
Verbatim wording from the response “I expect individual trusts and local health systems to effectively assess and manage bed capacity, the ‘flow’ of patients being discharged or moving to another setting and the availability of specialist personality disorder rehabilitation units. I recognise that mental health services have been under significant strain in recent years due to the rise in demand.” Source location Response from DHSC
Open published response
29 Oct 2024 Lee Armstrong · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 3 Lack of ambulance call-handler access to patients' medical records View source Failure to share information supplied to 111 online with ambulance call handlers View source Failure to elicit callers' existing medical conditions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lee Armstrong · 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
Lee Armstrong became unwell on 30 January 2024 and, after an initial ambulance-service call, became increasingly unwell before a further call led to an ambulance attending. He suffered an Addisonian Crisis, cardiac arrest and severe brain injury, and died on 2 February 2024. Concerns included the failure of the NHS Pathways system to ask about existing medical conditions, the lack of sharing of information supplied through 111 online with ambulance call handlers, and call handlers' lack of access to relevant medical 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 ambulance call-handler access to patients' medical records
Wider context from the report “(3) I note that NWAS call handlers are not provided with access to (even an abridged version) of a patient's medical records . I am concerned that this means that call handlers cannot see relevant details of medical history .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 supplied to 111 online with ambulance call handlers
Wider context from the report “(2) The evidence indicates that information supplied to 111 online is not shared with NWAS . This may mean that a caller expects that their medical history and condition are known by ambulance call handlers when this is not the case . This risks such callers not volunteering details of the medical history .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 elicit callers' existing medical conditions
Wider context from the report “(1) The evidence indicates that knowledge that Mr Armstrong suffered from Addison's Disease would have dramatically altered the response to the call. However, the NHS Pathways system does not ask callers to indicate whether they have any existing conditions . Instead, the onus is placed on patients to identify potentially relevant conditions . However, Mr Armstrong had indicated that he was confused. I am concerned that expecting a patient to volunteer crucial information about their condition, especially where that condition may cause confusion, places similar patients at risk .
” 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 NHS England will respond to concerns about sharing and accessing information from NHS 111 and patient records.
Verbatim wording from the response “reduce unwarranted variation across services, helping ensure appropriate prioritisation, equity of access and uniformity of response across England. In the case of Mr Armstrong, I understand that his pre-existing condition of Addison’s disease would have changed his call categorisation, and that NHS England, as the appropriate body, will be responding to your concerns raised on this matter as well as on the issue of appropriate patient record sharing and access to information gained from NHS 111. However, I would note that interpreting full medical records is outside of the scope and expectations of call handlers.” Source location Response from DHSC
Open published response
28 Oct 2024 Malcolm John TAYLOR · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1 Insufficient availability of beds to meet patient need View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Malcolm John TAYLOR · 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
Malcolm John TAYLOR, who had expressed self-harm and suicidal intent and was awaiting admission to a mental health hospital, probably entered the sea on 3 or 4 March 2024 and was found on Gorleston beach on 4 March 2024. He died from drowning. The report identified an insufficient number of available mental health hospital beds, with patients awaiting beds at the time of his death and the inquest.
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 beds to meet patient need
Wider context from the report “1. Evidence was heard from NSFT as to action they have taken in an attempt to increase the number of beds available and so to prevent future deaths, such as daily meetings of senior staff to discuss caseloads identified at high risk, prioritising those at high risk, weekly meetings with Directors and multi agencies to consider patient flow through the system and discussion with partner organisations to remove barriers to discharge to improve patient flow especially those with social care requirements. Despite these steps there remain insufficient beds available to meet patient need. At the time of Mr Taylor's death there were 13 patients awaiting beds. At the time of inquest, there were 7 patients awaiting beds. There are peaks and lows with these numbers on a daily basis but overall there remains a shortage of beds.
” 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 statutory guidance on discharge from mental health inpatient settings to support coordinated discharge planning.
Verbatim wording from the response “To help support such decisions, the Department published statutory guidance on Discharge from mental health inpatient settings in January 2024 and which is available at: Discharge from mental health inpatient settings - GOV.UK (www.gov.uk). This sets out how health and care systems should work together to support discharge from all mental health and learning disability and autism inpatient settings for children, young people and adults.” 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 working with the NHS to address mental health capacity across the system.
Verbatim wording from the response “I expect individual trusts and local health systems to effectively assess and manage bed capacity and the ‘flow’ of patients being discharged or moving to another setting. I recognise that mental health services have been under significant pressure in recent years due to the rise in demand and the Department will continue to work with the NHS to address capacity across the system.” 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 Ensure more mental health care is delivered in community settings through new models of care and support.
Verbatim wording from the response “As part of our mission to build an NHS fit for the future, we will make sure more mental health care is delivered in the community, close to people’s homes, through new models of care and support, so that fewer people need to go into hospital and that beds are available for when people need higher levels of support.” Source location Response from DHSC
Open published response
25 Oct 2024 Chloe Every · Prevention of Future Deaths report East London
View report summary
Concerns raised 8 Failure of Serious Incident investigations to identify healthcare failings View source Lack of nursing staff knowledge of criteria for commencing CPR on an unresponsive patient View source Lack of nursing cover during weekends and holiday periods by staff with relevant learning disability training View source Failure to maintain contemporary nursing and medical records of treatment and treatment decisions View source Delays in reporting deaths to a Coroner View source Failure to obtain informed consent before undertaking an enema View source Failure to undertake clinical observations at the expected frequency View source Failure of governance processes to identify patient safety incidents through mortality review 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
Chloe Every · 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
Chloe Every died in hospital on 14 May 2019 after complications from a hypoxic cardiac arrest sustained during her admission. The report identified concerns including morphine use without recorded justification, an enema undertaken without informed consent while she was unconscious, inadequate clinical observations, missing records, and failures in incident reporting and governance.
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 Serious Incident investigations to identify healthcare failings
Wider context from the report “7. A Serious Incident report completed by the trust in the second half of 2019 failed to identify a series of healthcare failings in Chloe’s treatment. Management failings at the Trust meant that Chloe’s death was not reported to a Coroner until August 2023, by which time Chloe’s body had been cremated denying the court an opportunity to gather relevant evidence through autopsy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 nursing staff knowledge of criteria for commencing CPR on an unresponsive patient
Wider context from the report “5. Nursing staff were incapable of explaining to the court the appropriate criteria that would have to exist before commencing CPR on an unresponsive patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of nursing cover during weekends and holiday periods by staff with relevant learning disability training
Wider context from the report “1. The Trust does not provide nursing cover during weekends and holiday periods of staff with relevant learning disability 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 Failure to maintain contemporary nursing and medical records of treatment and treatment decisions
Wider context from the report “2. The investigation of this inquest was prejudiced by the absence of contemporary nursing and medical notes from various stages of Chloe's treatment . The extent of these lapses meant staff who made important treatment decisions could not be identified, and where staff could be identified, no contemporary account of their rationale for making treatment decisions could be located .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 reporting deaths to a Coroner
Wider context from the report “7. A Serious Incident report completed by the trust in the second half of 2019 failed to identify a series of healthcare failings in Chloe’s treatment. Management failings at the Trust meant that Chloe’s death was not reported to a Coroner until August 2023 , by which time Chloe’s body had been cremated denying the court an opportunity to gather relevant evidence through autopsy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain informed consent before undertaking an enema
Wider context from the report “4. Chloe underwent an enema on 8th May 2019 without informed consent being taken . The court found that Chloe was unconscious, before, during, and after the procedure, it is possible this procedure contributed to 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 undertake clinical observations at the expected frequency
Wider context from the report “3. The regularity of Chloe’s clinical observations fell well below the expected level. The lapses included a period of over 10 hours in which no observations were undertaken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of governance processes to identify patient safety incidents through mortality review
Wider context from the report “6. Governance processes at the Trust failed to identify that Chloe’s death constituted a patient safety incident until months after her death. A mortality review authored by the Associated Medical Director on 17th May 2019 assessed Chloe’s care as good or excellent.
” 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 BHRUT is responsible for responding fully to the concerns, so the Department will not duplicate its response.
Verbatim wording from the response “NHSE have informed us that BHRUT is preparing a response to address your concerns in full. This is entirely appropriate due to the nature of the concerns raised and as a direct recipient of this report. I look forward to their response with interest and do not wish to duplicate it. However, I will highlight some points from the information shared with us, of the actions taken to improve matters in relation to the care of patients with learning disabilities since Chloe’s death in 2019:” Source location Response from DHSC
Open published response
25 Oct 2024 Wessam al Jundi · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Lack of adequate water suppression systems for dust created during artificial stone finishing View source Inadequate respiratory personal protective equipment for artificial stone finishing View source Absent or inadequate ventilation systems for artificial stone finishing View source Health surveillance failing to detect disease before it becomes untreatable 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
Wessam al Jundi · 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
Wessam al Jundi had severe silicosis and was admitted to Harefield Hospital on 17 May 2024 for a potential lung transplant, but was too unwell and died in hospital on 22 May 2024. The principal concern was that his untreatable lung disease was probably caused by workplace exposure to respirable crystalline silica from artificial stone products, in conditions described as unsafe and lacking adequate dust controls and respiratory 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 Lack of adequate water suppression systems for dust created during artificial stone finishing
Wider context from the report “The last 2 decades have seen rapid growth in the use of artificial stone and this death demonstrates the emergence of a severe progressive accelerated form of silicosis. Many of the companies specialising in the finishing process of working with this product have a small number of employees and their appears to be an absence of safe working conditions, with no adequate water suppression systems for the dust created , in adequate respiratory personal protection equipment and absent or inadequate ventilatory systems. This is therefore continuing to put the workforce at risk of death due to untreatable lung compromise.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 respiratory personal protective equipment for artificial stone finishing
Wider context from the report “The last 2 decades have seen rapid growth in the use of artificial stone and this death demonstrates the emergence of a severe progressive accelerated form of silicosis. Many of the companies specialising in the finishing process of working with this product have a small number of employees and their appears to be an absence of safe working conditions, with no adequate water suppression systems for the dust created, in adequate respiratory personal protection equipment and absent or inadequate ventilatory systems. This is therefore continuing to put the workforce at risk of death due to untreatable lung compromise.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absent or inadequate ventilation systems for artificial stone finishing
Wider context from the report “The last 2 decades have seen rapid growth in the use of artificial stone and this death demonstrates the emergence of a severe progressive accelerated form of silicosis. Many of the companies specialising in the finishing process of working with this product have a small number of employees and their appears to be an absence of safe working conditions, with no adequate water suppression systems for the dust created, in adequate respiratory personal protection equipment and absent or inadequate ventilatory systems . This is therefore continuing to put the workforce at risk of death due to untreatable lung compromise.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Health surveillance failing to detect disease before it becomes untreatable
Wider context from the report “Any current surveillance health and safety monitoring is unlikely to achieve a satisfactory outcome as the onset of untreatable disease predates the 15 year surveillance programmes. In this case exposure appears to have commenced in May 2016 and he was diagnosed with silicosis in 2021, a mere 5 years after initial exposure. Evidence from photographs and an in-life statement suggest Wessam was working in completely unsafe conditions to avoid dust exposure.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for addressing the Coroner’s concerns sits with the Health and Safety Executive.
Verbatim wording from the response “Our response to this PFD case suggested that responsibility for the Coroner’s concerns sits with HSE. It may be worth forwarding to them.” Source location Response from DHSC
Open published response
Concerns raised 2 Failure to clean injection-site skin before administering injections View source Training and national guidance failing to provide adequately current skin-disinfection requirements for injections View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Patricia Heather Lines · 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
Patricia Heather Lines became unwell after receiving an intramuscular Vitamin B12 injection into her right shoulder and died in hospital on 23 October 2023 after developing an invasive Group A Streptococcus infection. The report states that the likely source of the infection was the injection, with bacteria introduced from the skin into deeper shoulder tissues. A principal concern was that the administering nurse did not clean the skin, in accordance with existing training and national guidance, despite evidence that alcohol cleaning reduces bacterial counts and that the supporting literature was over 20 years old.
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 clean injection-site skin before administering injections
Wider context from the report “The nurse who administered the injection gave evidence that she did not clean the skin prior to administering the injection . She did not do so because she was following both her training (she quoted from an NHS e-learning module on administering intramuscular injections) and national guidance in the form of a document titled “Immunisation Against Infectious Disease”, which is also referred to as “The Green Book”.
Chapter 4 of “The Green Book” provides guidance on immunisation procedures. In relation to cleaning the skin the Green Book states as follows (at page 29):
If the skin is clean, no further cleaning is necessary. Only visibly dirty skin needs to be washed with soap and water.
It is not necessary to disinfect the skin. Studies have shown that cleaning the skin with isopropyl alcohol reduces the bacterial count, but there is evidence that disinfecting makes no difference to the incidence of bacterial complications of injections (Del Mar et al., 2001; Sutton et al., 1999).
The evidence that I heard at the inquest included that alcohol wipes are relatively cheap and their use does not give rise to any significant risk. I note that the Green Book states that cleaning the skin with alcohol reduces the bacterial count. Common sense would seem to suggest that reducing the bacterial count would reduce the risk of bacteria being inadvertently introduced into the deeper tissues during an injection. Whilst it is noted that the Green Book also makes reference to there being evidence that disinfecting makes no difference to the incidence of bacterial complications, it is also noted that the literature quoted is now over 20 years old.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Training and national guidance failing to provide adequately current skin-disinfection requirements for injections
Wider context from the report “The nurse who administered the injection gave evidence that she did not clean the skin prior to administering the injection. She did not do so because she was following both her training (she quoted from an NHS e-learning module on administering intramuscular injections) and national guidance in the form of a document titled “Immunisation Against Infectious Disease”, which is also referred to as “The Green Book”.
Chapter 4 of “The Green Book” provides guidance on immunisation procedures. In relation to cleaning the skin the Green Book states as follows (at page 29):
If the skin is clean, no further cleaning is necessary. Only visibly dirty skin needs to be washed with soap and water.
It is not necessary to disinfect the skin . Studies have shown that cleaning the skin with isopropyl alcohol reduces the bacterial count, but there is evidence that disinfecting makes no difference to the incidence of bacterial complications of injections (Del Mar et al., 2001; Sutton et al., 1999).
The evidence that I heard at the inquest included that alcohol wipes are relatively cheap and their use does not give rise to any significant risk. I note that the Green Book states that cleaning the skin with alcohol reduces the bacterial count. Common sense would seem to suggest that reducing the bacterial count would reduce the risk of bacteria being inadvertently introduced into the deeper tissues during an injection. Whilst it is noted that the Green Book also makes reference to there being evidence that disinfecting makes no difference to the incidence of bacterial complications, it is also noted that the literature quoted is now over 20 years old .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for immunisation procedure guidance lies with UKHSA, which is better positioned to address the reported issues.
Verbatim wording from the response “The Department has reviewed the concerns outlined in the report and, as responsibility for guidance on immunisation procedures, including the "The Green Book", lies with UK Health Security Agency (UKHSA), we have determined that they are better positioned to address these issues. Since UKHSA are also a named recipient in the report, we have engaged with them, and they have confirmed receipt of the report and are working on their response.” Source location Response from DHSC
Open published response
Concerns raised 2 Lack of available suitable placements for people with complex needs View source Inadequacy of the Section 136 Suite View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
DECLAN GORDON GERARD MORRISON · 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
Declan Morrison, who had complex care needs and required 24-hour residential care, was detained under the Mental Health Act after no suitable alternative placement could be found. He was found unresponsive after suffering catastrophic brain injuries and died in hospital on 2 April 2022. The principal concerns were the shortage of suitable community and NHS placements and the use of a Section 136 Suite considered inappropriate for his longer-term detention and complex needs.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of available suitable placements for people with complex needs
Wider context from the report “(1) The evidence revealed that there is currently a widespread shortage of available placements for someone with Declan’s complex needs both in the community and within the NHS .
(2) Once it was clear that Declan’s community placement had broken down in late 2021 no suitable alternative could be found . This resulted in a decline in Declan’s mental health and behaviour which ultimately necessitated his detention under the Mental Health Act. There was then nowhere suitable to detain him under Section 2 of the Mental Health Act .
(3) The Section 136 Suite was completely inappropriate. Declan’s mental health and behaviour declined further and ultimately this resulted in his death.
(4) Declan was in crisis for several months – the facilities were simply not available in the community and once detained , in order to prevent his 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 Inadequacy of the Section 136 Suite
Wider context from the report “(1) The evidence revealed that there is currently a widespread shortage of available placements for someone with Declan’s complex needs both in the community and within the NHS.
(2) Once it was clear that Declan’s community placement had broken down in late 2021 no suitable alternative could be found. This resulted in a decline in Declan’s mental health and behaviour which ultimately necessitated his detention under the Mental Health Act. There was then nowhere suitable to detain him under Section 2 of the Mental Health Act.
(3) The Section 136 Suite was completely inappropriate . Declan’s mental health and behaviour declined further and ultimately this resulted in his death.
(4) Declan was in crisis for several months – the facilities were simply not available in the community and once detained, in order to prevent his death.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the Mental Health Bill proposing Dynamic Support Register duties for people with learning disabilities and autistic people at risk of detention.
Verbatim wording from the response “As highlighted in your report, when no suitable placement could be found Declan was then detained under Section 2 of the Mental Health Act. Through our proposed reforms to the Mental Health Act 1983 (MHA), as set out in the Mental Health Bill introduced to parliament on 6th November 2024, integrated care boards (ICBs) will have a legal duty to ensure hold Dynamic Support Registers of people with a learning disability and autistic people who have risk factors for detention under Part II of the MHA. The Dynamic Support Register is intended to improve monitoring of the needs of, and support for, people who may be at risk of going into crisis and being detained under Part II of the MHA.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual trusts and local health systems are responsible for assessing and managing bed capacity, patient flow, and specialist unit availability.
Verbatim wording from the response “Individual trusts and local health systems are expected to effectively assess and manage bed capacity, the ‘flow’ of patients being discharged or moving to another setting and the availability of specialist units. NHS England’s 2024/25 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority – with local health systems directed to reduce the average length of stay in adult acute mental health wards to deliver more timely access to local beds. And in areas where there is a clear need for more beds, this has been addressed in part through investment in new units, as part of a whole system transformation approach.” Source location Response from DHSC
Open published response
21 Oct 2024 Henry Michael WILLEMS · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2 Delays in ambulance vehicles being released from hospitals View source Failure to meet applicable Category 2 ambulance response times View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Henry Michael WILLEMS · 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
Henry Michael WILLEMS collapsed at home in Malvern in the early hours of 12 October 2023 after being unwell with gastritis for 48 hours and was confirmed deceased after paramedics attended. The report identified concern that the ambulance response was substantially delayed, with expert evidence that he would probably have survived if paramedics had attended within the applicable 18-minute mean response time.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance vehicles being released from hospitals
Wider context from the report “1) In the course of the inquest, I heard evidence from the Patient Safety Learning Lead for West Midlands Ambulance Service University NHS Foundation Trust ( WMAS ), who told me:
(a) Mr. Willems’ case was correctly assigned a Category 2 disposition, for which the mean response time is 18 minutes, and the 90ᵗʰ percentile response time is 40 minutes;
(b) Those response times were not met, as Mr. Willems was not reached by paramedics until some 2 hours 18 minutes after the “clock start” time for his case;
(c) The Trust was unable to meet the applicable mean and 90ᵗʰ percentile response times, because at the time of these events, it was operating at Emergency and Urgent Service Level 4 (the highest level which can be applied ). The Trust had over 200 outstanding incidents, of which 31 were other Category 2 cases , and 50% of their vehicles were being delayed at hospitals within the region for anything between 189 minutes and 441 minutes .
2) I heard expert evidence that Mr. Willems would probably have survived this episode, and would not have died when he did, had paramedics been able to attend his home address within the applicable 18 minute mean response time.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 meet applicable Category 2 ambulance response times
Wider context from the report “1) In the course of the inquest, I heard evidence from the Patient Safety Learning Lead for West Midlands Ambulance Service University NHS Foundation Trust ( WMAS ), who told me:
(a) Mr. Willems’ case was correctly assigned a Category 2 disposition, for which the mean response time is 18 minutes, and the 90ᵗʰ percentile response time is 40 minutes;
(b) Those response times were not met, as Mr. Willems was not reached by paramedics until some 2 hours 18 minutes after the “clock start” time for his case ;
(c) The Trust was unable to meet the applicable mean and 90ᵗʰ percentile response times , because at the time of these events, it was operating at Emergency and Urgent Service Level 4 (the highest level which can be applied ). The Trust had over 200 outstanding incidents, of which 31 were other Category 2 cases, and 50% of their vehicles were being delayed at hospitals within the region for anything between 189 minutes and 441 minutes.
2) I heard expert evidence that Mr. Willems would probably have survived this episode, and would not have died when he did, had paramedics been able to attend his home address within the applicable 18 minute mean response time.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve hospital flow, reduce delayed discharges, and increase urgent and emergency care capacity.
Verbatim wording from the response “In the short-term, a range of action is being taken by the NHS this year to improve urgent and emergency care performance, including by maintaining capacity gains in acute hospital beds and ambulance hours on the road achieved in 2023-24, increasing the productivity of acute and non-acute services across bedded and non-bedded capacity, and directing patients to more appropriate services in the community where these can better meet their needs. This government is also working to improve hospital flow to make sure people do not spend longer than necessary in hospital and reduce delayed discharges, increasing urgent and emergency care capacity.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Return urgent and emergency care operations to the safe waiting-time standards set out in the NHS Constitution.
Verbatim wording from the response “At a national level, this government is committed to returning to the safe operational waiting time standards set out in the NHS Constitution. In doing so we will be honest about the challenges facing the health service and serious about tackling them. The Health Secretary ordered an independent investigation of NHS performance to provide an assessment of the issues and challenges it faces. This reported on 12th September 2024 and the investigation’s findings will feed into the government’s work on a 10-year plan to radically reform the NHS and build a health service that is fit for the future.” Source location Response from DHSC
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations