31 Jul 2024 Susan Pollitt · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 6 Failure to ensure clear identification and understanding of the Physician Associate role View source Lack of a clear mechanism for reporting concerns about individual Physician Associates View source Failure to require employers to verify Physician Associate registration View source Failure of competency assessments to cover the wider aspects of care for ascetic drain insertion View source Lack of regulatory oversight of Physician Associates View source Lack of a national framework for training, supervision and competence of Physician Associates View source See 3 more concerns
Responses linked to these concerns
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AI-generated summary
Susan Pollitt · 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 Pollitt was admitted to hospital after collapsing at home and developed ascites during her admission. An ascitic drain was inserted, remained in place for 21 hours, and was clamped; she developed bacterial peritonitis and died on 16 July 2023. The principal concerns included the lack of regulatory oversight and national training and competency frameworks for Physician Associates, and limited understanding of their role and responsibilities in managing ascitic drains.
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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 ensure clear identification and understanding of the Physician Associate role
Wider context from the report “4. There remains limited understanding and awareness of the role of a Physician Associate both amongst medical colleagues, patients and their families. The lack of a distinct uniform and the title “Physician” gives rise to confusion as to whether the practitioner is a doctor.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear mechanism for reporting concerns about individual Physician Associates
Wider context from the report “2. The Physicians Associate Managed Voluntary Register held by the Faculty of Physician Associates (FPA) is voluntary. Whilst employers are encouraged to check the register there is no duty to do so, nor is it clear how the FPA would be made aware of any concerns relating to an individual Physician Associate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to require employers to verify Physician Associate registration
Wider context from the report “2. The Physicians Associate Managed Voluntary Register held by the Faculty of Physician Associates (FPA) is voluntary. Whilst employers are encouraged to check the register there is no duty to do so , nor is it clear how the FPA would be made aware of any concerns relating to an individual Physician Associate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 competency assessments to cover the wider aspects of care for ascetic drain insertion
Wider context from the report “5. In June 2022 the Physicians Associate had been signed off as competent for the insertion of ascetic drains. This sign off was completed by a liver nurse specialist using a competency form which was provided by the FPA. Whilst the competency form assessed the technical aspect of placing the drain, it did not include competency around the wider aspects of care such as taking consent, risk factors and after care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory oversight of Physician Associates
Wider context from the report “1. There is no regulatory body with oversight of Physician Associates. It is understood that this is currently the subject of a consultation by the General Medical Council.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 national framework for training, supervision and competence of Physician Associates
Wider context from the report “3. There is no national framework as to how Physician Associates should be trained, supervised and deemed competent. This is placing both patients, Physicians Associates and their employers at risk. The Court heard that since the death of Mrs Pollitt the Northern Care Alliance have put in place a local trust framework. Unlike all other clinical roles there is no national guidance save for very recent guidance issued by the British Medical Association (March 2024).
” 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 The Faculty of Physician Associates, which developed the ascitic-drain competency form, is best placed to respond to concerns about it.
Verbatim wording from the response “In relation to the specific competency form you mention relating to the insertion of ascetic drains, we note that you have also written to the Faculty of Physician Associates. As the form has been developed by them, they will be best placed to respond on this point. However, it is worth reiterating that, as set out in NHS England’s guidance on the deployment of PAs in the NHS: “PAs must always work within their competencies; and must be supervised appropriately. Employers must ensure that the overall responsibility for supervision of PAs is by a named senior doctor.”” Source location Response from DHSC
Open published response
30 Jul 2024 Bethany Paige Langton · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 6 Continued public availability of online guidance on sourcing and using the substance for suicide View source Continued ease of public availability of the substance View source Failure to require explanation of purchasers’ intended use of the substance View source Lack of business awareness that the substance is being obtained for suicide View source Lack of a system for prompt detection and removal of websites providing guidance on sourcing and using the substance for suicide View source Failure to use end-user certification or licensing to track distribution of the substance View source See 3 more concerns
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AI-generated summary
Bethany Paige Langton · 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
Bethany Paige Langton, aged 22, was discovered deceased in her bedroom on 18 February 2023 after deliberately ingesting a substance sourced online with the intention of causing her death. The principal concerns were the substance’s easy online availability, limited awareness among businesses that it could be obtained for suicide, and the continued availability of online guidance about sourcing and using it for that purpose.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Continued public availability of online guidance on sourcing and using the substance for suicide
Wider context from the report “3. Beth used the internet to research how to source and use ████████ to bring about her death. She followed that guidance meticulously. That same guidance was still readily available on the internet at the time of her inquest , although I believe it might now have been removed. What system is in place to ensure that such websites are detected promptly and made unavailable to the public in a timely fashion?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Continued ease of public availability of the substance
Wider context from the report “1. The continued ease of availability of ████████ to members of the public.
The substance is lethal when ingested, even in relatively small quantities. It’s use in suicide is increasing. The substance is readily available to purchase online without the need for any explanation of the purchaser’s intended use for the substance, or an end user certificate/licence to track where it is being distributed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to require explanation of purchasers’ intended use of the substance
Wider context from the report “1. The continued ease of availability of ████████ to members of the public.
The substance is lethal when ingested, even in relatively small quantities. It’s use in suicide is increasing. The substance is readily available to purchase online without the need for any explanation of the purchaser’s intended use for the substance , or an end user certificate/licence to track where it is being distributed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 business awareness that the substance is being obtained for suicide
Wider context from the report “2. Lack of awareness amongst businesses that the substance is being obtained for this purpose.
The company who supplied Beth with the ████████ used in her death, had no idea that the substance might be sourced by individuals for this purpose . Had they have been aware of the risk, they would likely have improved systems for investigating the intended use, or would have stopped offering the item for sale to individuals, as they have now done so.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for prompt detection and removal of websites providing guidance on sourcing and using the substance for suicide
Wider context from the report “3. Beth used the internet to research how to source and use ████████ to bring about her death. She followed that guidance meticulously. That same guidance was still readily available on the internet at the time of her inquest, although I believe it might now have been removed. What system is in place to ensure that such websites are detected promptly and made unavailable to the public in a timely fashion?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 use end-user certification or licensing to track distribution of the substance
Wider context from the report “1. The continued ease of availability of ████████ to members of the public.
The substance is lethal when ingested, even in relatively small quantities. It’s use in suicide is increasing. The substance is readily available to purchase online without the need for any explanation of the purchaser’s intended use for the substance, or an end user certificate/licence to track where it is being distributed .
” 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 online suppliers and manufacturers to remove the substance from sale to individuals in its pure form.
Verbatim wording from the response “The group has worked with business, including online suppliers and manufacturers of the substance, to significantly reduce access. We have also worked with major online suppliers to remove it from sale to individuals in its pure form. We continue to work operationally with our broader partners, including Border Force and the police on interventions to reduce access to this specific substance for the purpose of suicide. These actions are kept under operational review.” 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 Work with internet service providers, technology companies, social media platforms and expert advisers to tackle harmful pro-suicide forums.
Verbatim wording from the response “The Act provides Ofcom with a robust suite of enforcement powers, including business disruptions measures and significant fines for use in the case of non-compliance. The Government has also worked with internet service providers, tech companies and social media platforms, as well as expert advisors such as the Samaritans, to tackle harmful pro-suicide forums.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue operational collaboration with Border Force, police and other partners to reduce access to the substance for suicide purposes.
Verbatim wording from the response “The group has worked with business, including online suppliers and manufacturers of the substance, to significantly reduce access. We have also worked with major online suppliers to remove it from sale to individuals in its pure form. We continue to work operationally with our broader partners, including Border Force and the police on interventions to reduce access to this specific substance for the purpose of suicide. These actions are kept under operational 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 Coordinate cross-sector work through an emerging methods working group to reduce public access to and awareness of suicide methods.
Verbatim wording from the response “The Government has taken steps to reduce access to and awareness of this substance and therefore reduce the risks of further deaths by suicide. The Department of Health and Social Care leads an emerging methods working group to prevent awareness and access to substances such as this one. The working group involves representatives from the voluntary, community and social enterprises sector, police, academics, and the NHS, as well as government departments including the Home Office and the Department for Science, Innovation and Technology. The group ensures rapid targeted actions to collectively reduce public access to emerging methods, including this particular substance. This includes reducing the sale and importation of methods where appropriate as well as reducing references to, and limiting awareness of, them.” Source location Response from DHSC
Open published response
Concerns raised 1 Delays in moving patients from the ED after a decision that they are ready to discharge View source
Responses linked to these concerns
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AI-generated summary
Colonel John Frederick Codd · 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
Colonel John Frederick Codd fell while exiting a taxi after a GP appointment and was taken by ambulance to hospital, where he waited outside for approximately 4 hours and 40 minutes before being admitted to the Emergency Department. He was later found in cardiac arrest and could not be resuscitated; the inquest recorded the cause of death as a massive rectus sheath haematoma and severe coronary artery atherosclerosis. The principal concerns were delays in hospital admission and ongoing Emergency Department crowding, which had the potential to affect future patient care.
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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 Delays in moving patients from the ED after a decision that they are ready to discharge
Wider context from the report “1) At the time of these events, (January 2024) monthly crowding analysis, that is the total amount of time patients spent waiting for beds or transport after a decision ‘ready to discharge’ from ED was made totalled 23,875 hours , the equivalent of closing 32 cubicles to ED for 24 hours/day for a whole month.
2) Last month, in June 2024, the situation had improved but still totalled 16,245 hours of lost time , the equivalent of closing 22 cubicles for an entire month.
████████ was clear in his evidence that significant pressures remained on the ED at Royal Cornwall Hospital which had the potential to affect future patient care .
” 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 Return to safe operational 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 report 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
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop local NHS-social care partnerships to reduce delayed discharges and prevent hospital departments being blocked.
Verbatim wording from the response “Regarding the concern raised about discharge delays, this government will make sure that hospital departments are no longer blocked due to delayed discharges. By developing local partnership working between the NHS and social care, we will ensure we no longer have over 12,000 patients every day waiting to be discharged.” Source location Response from DHSC
Open published response
25 Jul 2024 Leia Dorothy Pandora Sampson-Grimbly · Prevention of Future Deaths report North London
View report summary
Concerns raised 1 Excessively long waiting lists for first appointments at Gender Dysphoria clinics View source
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AI-generated summary
Leia Dorothy Pandora Sampson-Grimbly · 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
Leia Dorothy Pandora Sampson-Grimbly, aged 17, jumped from London Bridge into the Thames on 6 November 2024 and died in hospital later that day despite treatment. The report describes her being without preventative treatment amid lengthy waiting lists for a Gender Dysphoria clinic, alongside low mood, gender dysphoria, hostility from some sections of the community and social media links inciting suicide. The principal concern identified was that waiting lists were too long for a first appointment at a Gender Dysphoria clinic.
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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 Excessively long waiting lists for first appointments at Gender Dysphoria clinics
Wider context from the report “Waiting lists are far too long for first appointment at a Gender Dysphoria clinic.
” 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 the adult Gender Dysphoria Clinic review report and its findings and recommendations.
Verbatim wording from the response “The review is led by ████████, Medical Director of Lancashire and South Cumbria Integrated Care Board, and previously NHS England’s North West Regional Medical Director. Following on-site visits to every GDC in England, the report detailing the review’s findings and recommendations will be published in the autumn of 2025. The report will inform NHS England’s work to build a new service specification for the GDCs over 2025/26, which will involve a process of public consultation. In the context of reducing waiting times and waiting lists, NHS England will particularly want to learn the review’s findings and recommendations around productivity and efficiency within each of the GDCs.” Source location Response from Department for Health and Social Care
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 Conduct a review of adult Gender Dysphoria Clinic operations, service models, quality concerns and improvement actions.
Verbatim wording from the response “This response has focused on waiting times to Children and Young People’s Gender Services and NHS England’s efforts to increase clinical capacity in this field. However, it may assist HM Coroner to learn that in April 2024 NHS England took the decision to conduct a review of the operation and delivery of adult Gender Dysphoria Clinics (GDC), in line with the recommendations of the Cass Review and in recognition that waiting times for adult gender services are also unacceptably high.” Source location Response from Department for Health and Social Care
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 Develop a new service specification for adult Gender Dysphoria Clinics through public consultation.
Verbatim wording from the response “The review’s terms of reference and key lines of enquiry have been published, and they describe that the review will examine the operating procedures in each service; the appropriateness of the service model for the presenting population; areas of concern, and any action being taken to improve quality. It will identify areas for improvement in relation to service quality, good practice that could be shared with other clinics, and any support that should be made available to services to assist improvement.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation New clinical capacity cannot be built quickly because specialist staff require training and experience.
Verbatim wording from the response “It may assist HM Coroner to know that new clinical capacity cannot be built quickly given the specialist skills that are needed to staff the multi-disciplinary team comprised variously of psychologists, psychiatrists, psychotherapists, paediatricians, social workers, nurses and endocrinologists (not exhaustive). Clinicians require training and experience to build their expertise and competencies. That is why, to support a rapid build of a new clinical workforce, NHS England has commissioned the Academy of Medical Royal Colleges and University College London to design and deliver a professional competency framework and training curriculum by 2026.” Source location Response from Department for Health and Social Care
Open published response
25 Jul 2024 Elizabeth Grace Holder · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to prevent predictable and avoidable falls View source Failure of governance systems to identify and reflect upon failings in care View source Failure to remediate factors contributing to death View source
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AI-generated summary
Elizabeth Grace Holder · 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
Elizabeth Grace Holder, an 88-year-old woman recovering in hospital after surgery for a broken hip, fell while using a commode without supervision and died from a fatal intracerebral bleed. The concerns identified were that the Trust failed to prevent a predictable and avoidable fall and that its governance systems failed to identify care failings or act on factors contributing to her death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent predictable and avoidable falls
Wider context from the report “1. The Trust’s failure to prevent a predictable and therefore avoidable fall which resulted in 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 of governance systems to identify and reflect upon failings in care
Wider context from the report “2. Despite this incident activating the PSIRF process which resulted in the completion of an After Action Review (“AAR”), the Trust did not identify any sub-optimal aspects to Mrs Holder’s care. Accordingly, I have a concern regarding the failure of the Trust’s governance systems to;
a. Identify and reflect upon failings in care ,
b. Consequently, the failure of the trust to act in a way to remediate the factors that contributed to Mrs Holder’s 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 remediate factors contributing to death
Wider context from the report “2. Despite this incident activating the PSIRF process which resulted in the completion of an After Action Review (“AAR”), the Trust did not identify any sub-optimal aspects to Mrs Holder’s care. Accordingly, I have a concern regarding the failure of the Trust’s governance systems to;
a. Identify and reflect upon failings in care,
b. Consequently, the failure of the trust to act in a way to remediate the factors that contributed to Mrs Holder’s death .
” 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 The Trust is responsible for responding to concerns about its failures and explaining what went wrong.
Verbatim wording from the response “The report raises concerns over the Barts Health NHS Foundation Trust’s failure to prevent a predictable and therefore avoidable fall which resulted in death. Despite this incident activating the Patient Safety Incident Response Framework (PSIRF) at the Trust, no sub-optimal aspects to Mrs Holder’s care were identified. Thus, there are concerns around the failure of the Trust’s governance systems to:” 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 CQC will determine whether further regulatory action concerning the Trust’s PSIRF and governance is appropriate or necessary.
Verbatim wording from the response “I have been informed that the CQC will be discussing the PSIRF in upcoming meetings with the Trust. The CQC also continue to monitor the Trust and will consider whether further action is appropriate or necessary. I look forward to any developments which could provide a deeper understanding of the underlying issues at the Trust and help preventing future deaths such as Mrs Holder’s.” Source location Response from DHSC
Open published response
25 Jul 2024 David Alfred CURRY · Prevention of Future Deaths report Norfolk
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Concerns raised 1 Failure to provide timely urgent ureteroscopy within the P2 timescale View source
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AI-generated summary
David Alfred CURRY · 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
David Alfred Curry was admitted with an obstructing left ureteric stone, treated with an emergency ureteric stent, and later underwent ureteroscopy. He developed infection and sepsis following the procedure and died on 1 October 2023. The report raised concerns about delay in receiving the planned procedure, prolonged stent dwell time, limited theatre capacity, and the associated risk of urinary infection and sepsis.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely urgent ureteroscopy within the P2 timescale
Wider context from the report “2. Mr Curry required timely management; coded as Priority (P) 2. P2 is used to denote the ideal time frame for performing surgery and in the event of this procedure, P2 timescale typically means within 4 weeks.
3. Evidence was heard that the risk of post operative urinary infection and sepsis is increased by prolonged stent dwell time.
4. Due to a lack of theatre capacity, Mr Curry did not receive a date for the proposed procedure at the NHS Trust and some five months following the initial procedure he approached Spire Norwich Hospital on 5 September 2023. The procedure was carried out on 15 September 2023.
” 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 Elective capacity and theatre use are overseen through the relevant ICB’s Elective Recovery Board and participating Trusts.
Verbatim wording from the response “In preparing this response, Departmental officials have made enquiries with NHS England (NHSE). NHSE has raised your concerns directly with the Integrated Care Board (ICB) relevant to this case (Norfolk and Waveney ICB).” 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 Monitoring and mitigating harm from elective waiting lists is assigned to Trust and ICB clinical harm review groups.
Verbatim wording from the response “With regards to your concern over the increased risks of long waiting times for elective treatment, the Trust has a Clinical Harm Review Group which oversees compliance with guidelines for monitoring and mitigating the risk of harm to people on waiting lists. The ICB has recently established a System Clinical Harms Review Group with an overarching aim of keeping people on elective waiting lists safe. The Group will bring together key partners to share learning and reduce unwarranted variation in clinical harm review processes across the ICS, including clinical prioritisation processes which would have impacted this case. The Group will also highlight to the ERB any themes emerging in terms of harms to be reviewed, so such harms can be mitigated for future patients. In future, the Group will expand and provide further ‘waiting well’ initiatives alongside the current harm review processes.” Source location Response from DHSC
Open published response
24 Jul 2024 Regan Edwin James SMITH · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 4 Lack of national standards and guidance for the conduct of patient handovers at Accident and Emergency Units View source Lack of directly compatible ambulance and hospital IT systems for immediate availability of clinical information View source Failure of patient handover processes to ensure significant clinical findings are available to receiving clinicians View source Lack of national standards and guidance requiring confirmation that basic observations are received by Accident and Emergency personnel View source See 1 more concern
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AI-generated summary
Regan Edwin James SMITH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Regan Smith died at Kings College Hospital on 31 January 2023 after previously undiagnosed diabetes led to severe metabolic acidosis, multiorgan failure and acute liver failure. An abnormal blood glucose reading obtained by ambulance staff was not effectively handed over or recorded at hospital, resulting in his discharge without further glucose testing or treatment. The report identifies concerns about incompatible information systems, reliance on verbal handover during a period of high acuity, and the absence of national standards for emergency department handovers and confirmation of basic observations.
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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 national standards and guidance for the conduct of patient handovers at Accident and Emergency Units
Wider context from the report “The information to save Regan’s life (his abnormal blood glucose reading) was in the possession of the NHS at a time when lifesaving treatment could have been given to him on the 25th January 2023.
Regan’s death occurred as the result of an identifiable single point of failure (the ineffective handover process), as this led to a significant and known clinical finding being unavailable to his treating clinicians.
Evidence heard that the handover system in Regan’s case was reliant on both ambulance and Accident and Emergency personnel making and receiving a verbal handover. The IT systems used by the Ambulance and Hospital Trusts are not directly compatible, and therefore clinical information (such as blood glucose level test results) are not immediately available to hospital personnel in every case.
It was heard that Regan’s verbal only handover occurred during a period of very high acuity.
On the 25th January 2023 the unit was exceptionally busy, the staff there had a high number of other sick children to care for, there was no cubicle space available, and the staff had not been able to take any of their scheduled breaks. When Regan did see a clinician, it was in the corridor.
It was heard in evidence that there was no national protocol, no national standard operating procedures, and no National Institute for Health and Care Excellence guidance, in relation to the conduct of patient handovers at Accident and Emergency Units .
In addition, there is no national protocol, no national standard operating procedures, and no National Institute for Health and Care Excellence guidance, to ensure basic observations are confirmed as being received by the receiving Accident and Emergency personnel.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 directly compatible ambulance and hospital IT systems for immediate availability of clinical information
Wider context from the report “The information to save Regan’s life (his abnormal blood glucose reading) was in the possession of the NHS at a time when lifesaving treatment could have been given to him on the 25th January 2023.
Regan’s death occurred as the result of an identifiable single point of failure (the ineffective handover process), as this led to a significant and known clinical finding being unavailable to his treating clinicians.
Evidence heard that the handover system in Regan’s case was reliant on both ambulance and Accident and Emergency personnel making and receiving a verbal handover. The IT systems used by the Ambulance and Hospital Trusts are not directly compatible , and therefore clinical information (such as blood glucose level test results) are not immediately available to hospital personnel in every case .
It was heard that Regan’s verbal only handover occurred during a period of very high acuity.
On the 25th January 2023 the unit was exceptionally busy, the staff there had a high number of other sick children to care for, there was no cubicle space available, and the staff had not been able to take any of their scheduled breaks. When Regan did see a clinician, it was in the corridor.
It was heard in evidence that there was no national protocol, no national standard operating procedures, and no National Institute for Health and Care Excellence guidance, in relation to the conduct of patient handovers at Accident and Emergency Units.
In addition, there is no national protocol, no national standard operating procedures, and no National Institute for Health and Care Excellence guidance, to ensure basic observations are confirmed as being received by the receiving Accident and Emergency personnel.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 patient handover processes to ensure significant clinical findings are available to receiving clinicians
Wider context from the report “The information to save Regan’s life (his abnormal blood glucose reading) was in the possession of the NHS at a time when lifesaving treatment could have been given to him on the 25th January 2023.
Regan’s death occurred as the result of an identifiable single point of failure (the ineffective handover process ), as this led to a significant and known clinical finding being unavailable to his treating clinicians .
Evidence heard that the handover system in Regan’s case was reliant on both ambulance and Accident and Emergency personnel making and receiving a verbal handover . The IT systems used by the Ambulance and Hospital Trusts are not directly compatible, and therefore clinical information (such as blood glucose level test results) are not immediately available to hospital personnel in every case.
It was heard that Regan’s verbal only handover occurred during a period of very high acuity.
On the 25th January 2023 the unit was exceptionally busy, the staff there had a high number of other sick children to care for, there was no cubicle space available, and the staff had not been able to take any of their scheduled breaks. When Regan did see a clinician, it was in the corridor.
It was heard in evidence that there was no national protocol, no national standard operating procedures, and no National Institute for Health and Care Excellence guidance, in relation to the conduct of patient handovers at Accident and Emergency Units.
In addition, there is no national protocol, no national standard operating procedures, and no National Institute for Health and Care Excellence guidance, to ensure basic observations are confirmed as being received by the receiving Accident and Emergency personnel.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 national standards and guidance requiring confirmation that basic observations are received by Accident and Emergency personnel
Wider context from the report “The information to save Regan’s life (his abnormal blood glucose reading) was in the possession of the NHS at a time when lifesaving treatment could have been given to him on the 25th January 2023.
Regan’s death occurred as the result of an identifiable single point of failure (the ineffective handover process), as this led to a significant and known clinical finding being unavailable to his treating clinicians.
Evidence heard that the handover system in Regan’s case was reliant on both ambulance and Accident and Emergency personnel making and receiving a verbal handover. The IT systems used by the Ambulance and Hospital Trusts are not directly compatible, and therefore clinical information (such as blood glucose level test results) are not immediately available to hospital personnel in every case.
It was heard that Regan’s verbal only handover occurred during a period of very high acuity.
On the 25th January 2023 the unit was exceptionally busy, the staff there had a high number of other sick children to care for, there was no cubicle space available, and the staff had not been able to take any of their scheduled breaks. When Regan did see a clinician, it was in the corridor.
It was heard in evidence that there was no national protocol, no national standard operating procedures, and no National Institute for Health and Care Excellence guidance, in relation to the conduct of patient handovers at Accident and Emergency Units.
In addition, there is no national protocol, no national standard operating procedures, and no National Institute for Health and Care Excellence guidance, to ensure basic observations are confirmed as being received by the receiving Accident and Emergency personnel .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop IT support linking ambulance and emergency department systems to improve electronic clinical information sharing.
Verbatim wording from the response “The rapid exchange of clinical information verbally remains an integral part of communication. However, work is ongoing with NHSE to provide IT support that can deliver improved sharing of electronic information across systems. Linking the ambulance computer aided despatch system and electronic patient record collected by ambulance services with emergency departments data will provide better information about the patient journey.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out an ambulance dataset linking ambulance-service and emergency-department data through the emergency care data set.
Verbatim wording from the response “Further, to support learning and system improvement, an ambulance data set is also currently being rolled out across England. This will be achieved by linking patient data collected by ambulance services with data collected by emergency departments through the emergency care data set.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local process improvements and ambulance information systems provide an adequate response to clinical handover and patient-record concerns.
Verbatim wording from the response “Regarding the formal clinical handover of patients, there are a number of protocols that should be followed. This includes standards set out by the General Medical Council on how patient information should be shared, and the NHS standard contract which sets out targets on handover delays. The responsibility for the implementation and oversight of protocols across England is at a local level. I understand that ESNEFT submitted evidence during the inquest which set out actions being taken locally to improve processes which you have considered and were content with. EEAST advise that in the East of England, all hospital A&Es have information systems to provide records of patients arriving by ambulance and that they are ensuring that ambulance patient care records are available as part of the assessment of patients who arrive at A&E by ambulance.” 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 Implementation and oversight of clinical handover protocols across England are the responsibility of local organisations.
Verbatim wording from the response “Regarding the formal clinical handover of patients, there are a number of protocols that should be followed. This includes standards set out by the General Medical Council on how patient information should be shared, and the NHS standard contract which sets out targets on handover delays. The responsibility for the implementation and oversight of protocols across England is at a local level. I understand that ESNEFT submitted evidence during the inquest which set out actions being taken locally to improve processes which you have considered and were content with. EEAST advise that in the East of England, all hospital A&Es have information systems to provide records of patients arriving by ambulance and that they are ensuring that ambulance patient care records are available as part of the assessment of patients who arrive at A&E by ambulance.” Source location Response from DHSC
Open published response
23 Jul 2024 Nathan Tesla George Scantlebury · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1 Lack of suitable placements for high-risk children with complex mental health needs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nathan Tesla George Scantlebury · 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
Nathan Scantlebury, aged 16, died in hospital shortly after being found unresponsive with a ████████ tight around his neck on 25 September 2019. The principal concerns were the lack of suitable placements for children with complex mental health needs and failures relating to the suitability and management of his placement and care arrangements.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of suitable placements for high-risk children with complex mental health needs
Wider context from the report “The lack of availability of suitable placements for high risk children with complex mental health needs which is both a local and a national issue which has been ongoing for a number of years.
” 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 Redesign inpatient mental health care toward timely, effective, person-centred community-based provision for children and young people.
Verbatim wording from the response “The model of inpatient mental health care is being re-designed to enable the move to a more community-based provision of care, where children and young people can access appropriate mental health support in a timely, effective, and person-centred way, at home or close to home and in the least restrictive environment.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England will address the concerns about suitable placements for high-risk children with complex mental health needs.
Verbatim wording from the response “In preparing this response, my Departmental officials have made enquiries with NHS England and Cheshire and Merseyside Integrated Care Board and I understand that NHS England will address your concerns in more detail in its response. We will work with colleagues at NHS England to ensure the appropriate steps are taken to avoid a repetition of this tragedy.” Source location Response from DHSC
Open published response
22 Jul 2024 Omar Abdi Ahmed · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Failure of district nursing staff to identify risks when patients disengage from treatment View source Failure to challenge refusal to use central heating View source Under-resourcing of the district nursing team View source Failure of domiciliary care to provide essential cleaning, personal care and meal support View source Failure of communication between care providers and public services to identify deterioration in living conditions and health View source Failure to challenge unsafe budgeting decisions affecting access to food and cleaning materials View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Omar Abdi Ahmed · 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
Omar Abdi Ahmed, who had significant comorbidity and bilateral lower-limb amputations, was found unresponsive and severely hypothermic at home on 15 November 2023 after receiving domiciliary and district nursing care. He died in hospital on 20 November 2023; the inquest concluded that hypothermia, with pneumonia and ischaemic heart disease contributing, was the medical cause of death. Concerns included poor communication between care organisations, shortcomings in district nursing oversight, and domiciliary care arrangements that did not adequately address his personal care, nutrition, cleaning, and heating 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 Failure of district nursing staff to identify risks when patients disengage from treatment
Wider context from the report “2. Evidence heard in the inquest suggested an under-resourced and demoralised district nursing team lacked the clinical curiosity to predict the harm that would befall Mr Ahmed should he be allowed to disengage from 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 challenge refusal to use central heating
Wider context from the report “3. Mr Ahmed’s poor decision-making in how he budgeted was never challenged, this led to a lack of nutritious food and cleaning materials in his home. Similarly, Mr Ahmed’s unwillingness to turn on his central heating , a contributory factor in the development of his fatal condition -hypothermia, remained unchallenged at the time of his death .
Domiciliary carers capitulated to Mr Ahmed’s express wishes that they ought not assist him with cleaning, personal care or meals instead, state-funded care hours were utilised to assist Mr Ahmed in attending his local pub and café.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Under-resourcing of the district nursing team
Wider context from the report “2. Evidence heard in the inquest suggested an under-resourced and demoralised district nursing team lacked the clinical curiosity to predict the harm that would befall Mr Ahmed should he be allowed to disengage from 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 of domiciliary care to provide essential cleaning, personal care and meal support
Wider context from the report “3. Mr Ahmed’s poor decision-making in how he budgeted was never challenged, this led to a lack of nutritious food and cleaning materials in his home. Similarly, Mr Ahmed’s unwillingness to turn on his central heating, a contributory factor in the development of his fatal condition -hypothermia, remained unchallenged at the time of his death.
Domiciliary carers capitulated to Mr Ahmed’s express wishes that they ought not assist him with cleaning, personal care or meals instead, state-funded care hours were utilised to assist Mr Ahmed in attending his local pub and café .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between care providers and public services to identify deterioration in living conditions and health
Wider context from the report “1. Poor standards of communication between the domiciliary care company, the local authority and NHS trust resulted in a failure to identify the deterioration in Mr Ahmed’s living conditions and health .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 challenge unsafe budgeting decisions affecting access to food and cleaning materials
Wider context from the report “3. Mr Ahmed’s poor decision-making in how he budgeted was never challenged , this led to a lack of nutritious food and cleaning materials in his home . Similarly, Mr Ahmed’s unwillingness to turn on his central heating, a contributory factor in the development of his fatal condition -hypothermia, remained unchallenged at the time of his death.
Domiciliary carers capitulated to Mr Ahmed’s express wishes that they ought not assist him with cleaning, personal care or meals instead, state-funded care hours were utilised to assist Mr Ahmed in attending his local pub and café.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the first part of the Care Workforce Pathway for adult social care.
Verbatim wording from the response “While employers in the health and care sector have ultimate responsibility to satisfy themselves regarding the skills and competence of their staff, DHSC also provides support. On January 10th, 2024, the DHSC published the first part of the Care Workforce Pathway, a new national career framework for the adult social care sector. This pathway defines knowledge, skills, values, and behaviours of those working in, or wanting to work in adult social care, should have. Although not mandatory, it is designed to improve how providers can support and develop their workforce. The Pathway is being developed to work in conjunction with existing standards and competency frameworks. The Care Quality Commission (CQC) will look at a provider's approach to staff induction, support and training using CQC's key lines of enquiry.” 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 Develop the Care Workforce Pathway to work alongside existing standards and competency frameworks.
Verbatim wording from the response “While employers in the health and care sector have ultimate responsibility to satisfy themselves regarding the skills and competence of their staff, DHSC also provides support. On January 10th, 2024, the DHSC published the first part of the Care Workforce Pathway, a new national career framework for the adult social care sector. This pathway defines knowledge, skills, values, and behaviours of those working in, or wanting to work in adult social care, should have. Although not mandatory, it is designed to improve how providers can support and develop their workforce. The Pathway is being developed to work in conjunction with existing standards and competency frameworks. The Care Quality Commission (CQC) will look at a provider's approach to staff induction, support and training using CQC's key lines of enquiry.” 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 Employers have ultimate responsibility for ensuring health and care staff possess the necessary skills and competence.
Verbatim wording from the response “While employers in the health and care sector have ultimate responsibility to satisfy themselves regarding the skills and competence of their staff, DHSC also provides support. On January 10th, 2024, the DHSC published the first part of the Care Workforce Pathway, a new national career framework for the adult social care sector. This pathway defines knowledge, skills, values, and behaviours of those working in, or wanting to work in adult social care, should have. Although not mandatory, it is designed to improve how providers can support and develop their workforce. The Pathway is being developed to work in conjunction with existing standards and competency frameworks. The Care Quality Commission (CQC) will look at a provider's approach to staff induction, support and training using CQC's key lines of enquiry.” Source location Response from DHSC
Open published response
22 Jul 2024 Gemima CHRISTODOULOU-PEACE · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 4 Delays in access to prescribing mental health practitioners View source Limited recording of telephone interactions with patients View source Lack of a single reference point for identifying medications that increase suicidal behaviour View source Failure to provide accessible telephone call recordings for clinical review 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
Gemima CHRISTODOULOU-PEACE · 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
Gemima Christodoulou-Peace was found suspended by her neck from a ligature and died from suspension hanging, with the inquest noting insufficient evidence that she intended her death at all material times. The report raises concerns about the absence of a single reference point for identifying medications associated with increased suicidal behaviour, limited recording and accessibility of mental-health telephone calls, and delays in access to prescribing mental-health support. Gemima had requested a medication review, but had not seen a prescribing mental-health practitioner before her death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in access to prescribing mental health practitioners
Wider context from the report “3. Gemima first reported a decline in her mental health in March 2023 and requested to be put back onto her previous medication. Gemima’s GP could not do this without input from a prescribing mental health practitioner, so a referral to secondary Mental Health Services was made. Gemima’s March request did not result in her obtaining an appointment with a prescribing mental health practitioner, at that time.
Gemima reported her continuing low mood to her GP again on the 3rd July 2023, but as she had been referred to a Wellbeing Team, was told to contact NHS 111 Option 2 if she was ‘in crisis’.
On the 19th July 2023 Gemima told her GP her anxiety was ‘through the roof’ so an urgent referral to the Mental Health Services was made.
Gemima was assessed over the telephone six days later on the 25th July 2023, and was offered crisis support which she declined, as Gemima wanted a medication review with the mental health team she had seen previously.
On the 25th July 2023 a risk assessment was undertaken with Gemima, and using the RAG (Red, Amber, Green) system, Gemima was deemed to be an ‘Amber’, and therefore ‘moderate’ risk.
The court heard that any case risk rated ‘Red’, had a target response time of 4-72 hours (if the patient was in crisis) and 7 days for other ‘Red’ cases. Any case risk rated ‘Amber’ had a target response time of 2 to 4 weeks, and any case rated ‘Green’ had a target response time of 28 days.
All treating clinicians who gave evidence in Gemima’s case said ‘in an ideal world’ resources would allow for much more timely interventions than those currently possible, especially those cases rated ‘Red’ or ‘Amber’.
Although Gemima herself had recognised the need to be back on her mental health medication, resource pressures meant that at the time of her death, she had still not seen a treating mental health practitioner who could prescribe her previous mental health prescription.
Gemima’s treatment assessment was booked for the 8th August 2023, 14 days after her tragic 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 Limited recording of telephone interactions with patients
Wider context from the report “2. There are currently only a limited number of calls going into the Norfolk and Suffolk Foundation Trust which are being recorded.
As such, should the clinician taking the call suddenly need to be absent (e.g. sudden ill health, domestic emergency, etc) and therefore cannot provide details of the call, there is no way any other treating clinician can respond to needs of that patient, or address any risks to that patient identified in that call.
In addition, without a recording of calls there is no opportunity to review cases were there may be some doubt as to what a patient or clinician has said, or when a different clinician wishes to hear the patient themselves to independently assess the patients presentation, or for a Multi-Disciplinary Team to review the contents of that call.
As many interactions between the NSFT and patients are telephone based, the availability of accurate recording of those conversations, and increased accessibility to them, would improve patient safety.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a single reference point for identifying medications that increase suicidal behaviour
Wider context from the report “1. Currently a treating clinician would need to undertake independent review on every prescription medication a patient is taking, to identify if any of those medications have a reported side-effect of increasing suicidal behaviour.
For some medications this side-effect is very rare, so it is highly unlikely that a treating clinician could know all the medications identified as having a risk of increasing suicidal behaviour.
At present there is no single reference point which a treating clinician can access, to readily and quickly identify if a patient is on a prescribed medication which is known to increase suicidal behaviour.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accessible telephone call recordings for clinical review
Wider context from the report “2. There are currently only a limited number of calls going into the Norfolk and Suffolk Foundation Trust which are being recorded.
As such, should the clinician taking the call suddenly need to be absent (e.g. sudden ill health, domestic emergency, etc) and therefore cannot provide details of the call, there is no way any other treating clinician can respond to needs of that patient, or address any risks to that patient identified in that call.
In addition, without a recording of calls there is no opportunity to review cases were there may be some doubt as to what a patient or clinician has said, or when a different clinician wishes to hear the patient themselves to independently assess the patients presentation, or for a Multi-Disciplinary Team to review the contents of that call.
As many interactions between the NSFT and patients are telephone based, the availability of accurate recording of those conversations, and increased accessibility to them , would improve patient safety.
” 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 Recruit 8,500 additional, specially trained mental health workers to reduce delays and provide faster treatment for people at risk of suicide.
Verbatim wording from the response “More broadly, it is unacceptable that too many people, like Gemima, are not receiving the mental health care they need when they need it and we know that waits for mental health services are far too long. We are determined to change that. As part of our mission to build an NHS that is fit for the future and that is there when people need it, we will modernise the Mental Health Act to give greater choice, autonomy, enhanced rights and support, and ensure everyone is treated with dignity and respect throughout treatment and recruit an additional 8,500 mental health workers to reduce delays and provide faster treatment which will also help ease pressure on busy mental health services. These new workers will be specially trained to support people at risk of suicide.” 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 Prescribers are responsible for using the Summary of Product Characteristics to prescribe medicines safely.
Verbatim wording from the response “Information including the reported frequency of adverse drug reactions can be found in the Patient Information Leaflet and Summary of Product Characteristics which accompanies every licensed medicine marketed in the UK, including montelukast. The Summary of Product Characteristics forms the legal basis for the correct use of a medicinal product. It provides all the necessary information for prescribers to use a product safely and should be used to inform any discussions with a patient about the risks as well as the benefits of their treatment. The Patient Information Leaflet supplied with a patient’s medicine also supports those discussions and can be a useful reference to ensure patients are informed about their treatment. It is the prescriber’s responsibility to prescribe a drug based on the information contained within the Summary of Product Characteristics.” 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 Recording all clinical calls is considered disproportionate; recording remains limited to NHS 111 and designated crisis-team lines.
Verbatim wording from the response “Turning to your concerns around the recording of incoming phone calls made to the Norfolk and Suffolk NHS Foundation Trust, I can appreciate the potential risks this may pose, as you have highlighted. The Trust has advised that it has recently considered the issue of recording clinical calls and taken the decision that it would be proportionate to extend clinical call recording from NHS 111 (option 2) only to within crisis teams within the organisation and all phone lines which have been designated as requiring recording facility have now been enabled.” Source location Response from DHSC
Open published response
17 Jul 2024 Pauline SPEDDING · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2 Failure to maintain continuity of inpatient care during ward moves View source Lack of sufficient inpatient capacity resulting in use of escalation beds and corridors 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
Pauline SPEDDING · 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
Pauline Spedding, who had a history of falls and was assessed as being at high risk, suffered a fall in hospital on 24 March 2023, developed a large subdural haematoma and died later that morning. The report identifies concerns about multiple ward moves, incomplete falls-risk and care documentation, failure to notify the Falls Response Team, and hospital capacity pressures involving escalation beds.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain continuity of inpatient care during ward moves
Wider context from the report “2. Mrs Spedding was moved between five wards during her inpatient stay between 7 March 2023 and her death on 24 March 2023, resulting in breaks in the continuity of care for Mrs Spedding and the requirement for more risk assessments to be carried out and documentation to be completed by staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficient inpatient capacity resulting in use of escalation beds and corridors
Wider context from the report “3. The reason for the number of moves between wards was given as being due to excess beds being required in hospital over and above those which would usually be expected , as a result of difficulties with the number of patients being admitted and those able to be discharged .
4. Evidence was heard that corridors are being used to accommodate patients and seven beds are being placed in wards intended for six beds . These additional beds are referred to as “escalation beds”.
5. Evidence was heard that in 2023 there were 44 escalation beds in use and for June 2024 there were 66 escalation beds in use. During the winter of 2023/2024 the number of escalation beds rose to 120. The Falls Prevention and Management Lead for the hospital referred to the elderly population in Norfolk and life expectancy being lower with resultant health issues in many parts of the county and felt it unlikely that the hospital would not need escalation beds in the foreseeable future .
” Open source report
17 Jul 2024 Lorraine Julia Proctor · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Delays in cardiology specialist appointments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Lorraine Julia Proctor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lorraine Julia Proctor had a history of cardiac health issues and was found unresponsive at home on 22 December 2023. A post-mortem identified acute myocardial ischaemia, coronary artery atheroma and ischaemic cardiomyopathy as the direct causes of death. The report raised concerns about lengthy cardiology waiting lists delaying specialist input for patients, although it was stated that an earlier appointment was unlikely to have changed Ms Proctor’s treatment.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in cardiology specialist appointments
Wider context from the report “The inquest was told that there are significant backlogs for cardiology appointments not just in Greater Manchester but nationally . The reasons the inquest was told were multi factorial and included demand, resources available, covid backlogs and the impact of strike action.
As a consequence patients referred for first cardiology appointments from primary care are often waiting in excess of 40 weeks for a first specialist appointment and existing cardiology patients are also waiting similar periods of time for follow up appointments .
In Ms Proctor’s case the inquest was told that it was unlikely that there would have been a change to the treatment she was on even if she had been seen. However it was clear that this would not always be the case and patients requiring specialist input were not receiving it within the timescales that reduced the risk of complications and 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 Achieve the NHS Constitutional standard that 92% of patients wait no longer than 18 weeks from referral to treatment by the end of this parliament.
Verbatim wording from the response “I want to assure you that tackling waiting lists is a top priority for this government, as we work to get the NHS back on its feet. We have committed to achieving the NHS Constitutional standard that 92% of patients should no longer than 18 weeks from Referral to Treatment (RTT), by the end of this parliament.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional regional and national support and scrutiny to trusts with the largest elective-care backlogs, including Manchester University NHS Foundation Trust.
Verbatim wording from the response “We recognise that it is unacceptable that some patients are waiting over 40 weeks for cardiology first appointments and too long for post treatment follow ups. NHS England (NHSE) is taking forward a programme of work to transform outpatient services, to ensure that patients can be seen more quickly and give patients more choice and flexibility about their treatment. The NHS and Department are also providing additional regional and national” 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 Work towards eliminating elective-care waits exceeding 65 weeks by September 2024, consistent with NHS England’s 2024–25 planning guidance.
Verbatim wording from the response “support and scrutiny to the most challenged trusts with the largest backlogs, including Manchester University NHS Foundation Trust, and continue to work towards the target in NHSE’s 24/25 planning guidance to eliminate waits of over 65 weeks by September 2024.” Source location Response from DHSC
Open published response
15 Jul 2024 Megan Davison · Prevention of Future Deaths report Hertfordshire
View report summary
Concerns raised 5 Failure of shared clinical records systems to include private providers View source Lack of integrated healthcare system for diabetes and eating disorders View source Incomplete treatment pathway for DKA View source Lack of treatment pathway for T1DE View source Lack of formal diagnosis for T1DE View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Megan Davison · 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
Megan Davison was found deceased at home on 4 August 2017 after hanging herself with the intention of ending her life. The report identified concerns about her discharge from mental health care, limited integration between physical and mental healthcare, the absence of recognised diagnosis and care pathways for Type 1 Diabetes with Disordered Eating and Diabetic Ketoacidosis, and incomplete information-sharing between healthcare providers.
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 shared clinical records systems to include private providers
Wider context from the report “(c) Whilst there have been significant advances in developing shared clinical records systems across primary and secondary care since Ms Davison's death in 2017, none of the shared records systems extends to organisations which are deemed to be private providers , such as The Priory. The perception of healthcare providers such The Priory as "private" providers is a fallacy, because a high percentage of patients looked after by such providers are, like Ms Davison, NHS patients. I heard evidence from the Chief Medical Officer of The Priory that record sharing which includes private providers would help to prevent future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of integrated healthcare system for diabetes and eating disorders
Wider context from the report “(b) At a local level in East and North Hertfordshire there is no integrated healthcare system for patients with diabetes and eating disorders as there is in the west of the county.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Incomplete treatment pathway for DKA
Wider context from the report “(a) On a national level there is not a system which is capable of being operated in a way which will ensure proper integrated healthcare for patients with T1DE. Specifically, there is no formal diagnosis for T1DE, no treatment pathway for T1DE and no complete treatment pathway for Diabetic Ketoacidosis (DKA) , an acute clinical emergency associated with T1DE caused by deliberate omission of insulin, which should be seen as an act of self harm - there being a physical protocol, but no mental health protocol, for DKA . I heard independent evidence from ████████, Professor of Psychiatry and Medicine at the Institute of Psychiatry, Psychology and Neurosciences at Kings College London that "the lack of a diagnosis for T1DE has an impact because if you don’t know what you are looking for and there aren’t any criteria that you can screen by then it’s very difficult for both patients and clinicians to understand what is wrong with them and this has hampered development of recognition and treatment pathways and building the research evidence". (Copies of ████████'s independent expert reports for the Inquest are attached).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 treatment pathway for T1DE
Wider context from the report “(a) On a national level there is not a system which is capable of being operated in a way which will ensure proper integrated healthcare for patients with T1DE. Specifically, there is no formal diagnosis for T1DE, no treatment pathway for T1DE and no complete treatment pathway for Diabetic Ketoacidosis (DKA), an acute clinical emergency associated with T1DE caused by deliberate omission of insulin, which should be seen as an act of self harm - there being a physical protocol, but no mental health protocol, for DKA. I heard independent evidence from ████████, Professor of Psychiatry and Medicine at the Institute of Psychiatry, Psychology and Neurosciences at Kings College London that "the lack of a diagnosis for T1DE has an impact because if you don’t know what you are looking for and there aren’t any criteria that you can screen by then it’s very difficult for both patients and clinicians to understand what is wrong with them and this has hampered development of recognition and treatment pathways and building the research evidence". (Copies of ████████'s independent expert reports for the Inquest are attached).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 formal diagnosis for T1DE
Wider context from the report “(a) On a national level there is not a system which is capable of being operated in a way which will ensure proper integrated healthcare for patients with T1DE. Specifically, there is no formal diagnosis for T1DE , no treatment pathway for T1DE and no complete treatment pathway for Diabetic Ketoacidosis (DKA), an acute clinical emergency associated with T1DE caused by deliberate omission of insulin, which should be seen as an act of self harm - there being a physical protocol, but no mental health protocol, for DKA. I heard independent evidence from ████████, Professor of Psychiatry and Medicine at the Institute of Psychiatry, Psychology and Neurosciences at Kings College London that "the lack of a diagnosis for T1DE has an impact because if you don’t know what you are looking for and there aren’t any criteria that you can screen by then it’s very difficult for both patients and clinicians to understand what is wrong with them and this has hampered development of recognition and treatment pathways and building the research evidence". (Copies of ████████'s independent expert reports for the Inquest are attached).
” 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 Responses to pressures on mental health services, private-NHS interfaces and information sharing are local matters for the Integrated Care Board.
Verbatim wording from the response “Thank you for also highlighting your important concerns about the pressures on NHS mental health services, the interface between private practitioners and NHS providers and the sharing of medical information between the two. I note that your report has also been sent to the Hertfordshire and West Essex Integrated Care Board as this is a local matter and I would expect that the ICB will want to ensure the appropriate steps are taken in response.” 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 Long-term sustainable provision of T1DE care is the responsibility of Hertfordshire and West Essex Integrated Care Board.
Verbatim wording from the response “Central to the service model delivered in the eight pilot sites, which are distributed in each region of the country, is delivery of a model treatment and care pathway that integrates various healthcare disciplines, including diabetes and mental health to address the complex nature of T1DE. Funding has been provided on a pump prime basis and the responsibility for the longer-term sustainable provision of care for these patients sits with Hertfordshire and West Essex Integrated Care Board.” 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 Future national T1DE plans depend on future NHS spending settlements and the level of NHS England funding allocated to T1DE.
Verbatim wording from the response “NHS England is drawing on learning from existing T1DE services, other emerging evidence and the findings of the recent ‘Type 1 diabetes and disordered eating’ parliamentary inquiry on the 23 January 2024, to ensure all areas of the country are supported to improve care for those identified as having T1DE. The emergence of these future plans are subject to future spending review settlements for the NHS and level of funding from the NHS England budget allocated to T1DE.” Source location Response from DHSC
Open published response
12 Jul 2024 Ryleigh Hillcoat - Bee · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 2 Lack of awareness and recognition of rhabdomyolysis among paediatricians in general paediatric departments View source Limited guidance on rhabdomyolysis in young children View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ryleigh Hillcoat - Bee · 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
Ryleigh Hillcoat - Bee died after cardiac arrest from complications of rhabdomyolysis associated with an inherited Lipin-1 deficiency. The report raises concerns about limited awareness of rhabdomyolysis among general paediatricians, scarce clinical guidance, and the risk that future cases in young children may go unrecognised with fatal consequences.
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 awareness and recognition of rhabdomyolysis among paediatricians in general paediatric departments
Wider context from the report “• Ryleigh died from a rare condition, but one known to affect young children. There is a clear lack of awareness of the condition amongst paediatricians in general paediatric departments.
• In my view there is a strong likelihood that previous cases of rhabdomyolysis in young children have been missed .
• What guidance is available appears to be very limited.
• In the event other young children attend a general paediatric department in the future for reasons connected to rhabdomyolysis, there is a concern the condition will go unrecognized and with fatal consequences.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Limited guidance on rhabdomyolysis in young children
Wider context from the report “• Ryleigh died from a rare condition, but one known to affect young children. There is a clear lack of awareness of the condition amongst paediatricians in general paediatric departments.
• In my view there is a strong likelihood that previous cases of rhabdomyolysis in young children have been missed.
• What guidance is available appears to be very limited.
• In the event other young children attend a general paediatric department in the future for reasons connected to rhabdomyolysis, there is a concern the condition will go unrecognized and with fatal consequences.
” 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 Genomics Education Programme and Medics for Rare Diseases on solutions addressing limited rare-disease guidance, workforce awareness, education and training.
Verbatim wording from the response “With respect to the specific concerns raised in the report, where guidance and workforce awareness appear to be limited and further education and training is required, the GEP will contribute by working with the Department and in collaboration with Medics for Rare Diseases (M4RD) on a number of solutions aligned to some of the actions above.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing paediatric curricula are considered sufficient; paediatricians need awareness of serious illness and referral rather than complete rhabdomyolysis expertise.
Verbatim wording from the response “to NHSE by RCPCH. The information provided by RCPCH clarifies that in line with the GMC expectations of curricula and 'excellence by design', they do not have a list of specific conditions included. Their curriculum is an outcomes based one with high level generic learning outcomes which focus on professional and clinical behaviours and capabilities.” 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 specialist guidance is considered sufficient because NICE cannot extend it beyond the available evidence.
Verbatim wording from the response “Officials engaged NICE with respect to your concern around a lack of guidance on rare diseases. NICE state that they do not usually produce guidance on the management of rare diseases as there is usually limited high quality evidence available on which to base guidance on. Therefore, guidance for rare conditions is usually developed by groups of interested clinicians or specialist societies and by consensus. NICE advise that specialist guidance already exists for the conditions in question, and, with limited evidence, they would not be able to go beyond that existing guidance.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Limited high-quality evidence prevents NICE from going beyond existing specialist guidance for these rare conditions.
Verbatim wording from the response “Officials engaged NICE with respect to your concern around a lack of guidance on rare diseases. NICE state that they do not usually produce guidance on the management of rare diseases as there is usually limited high quality evidence available on which to base guidance on. Therefore, guidance for rare conditions is usually developed by groups of interested clinicians or specialist societies and by consensus. NICE advise that specialist guidance already exists for the conditions in question, and, with limited evidence, they would not be able to go beyond that existing guidance.” Source location Response from DHSC
Open published response
Concerns raised 6 Lack of clarity in referral and crisis-support processes for patients receiving private and NHS treatment View source Unavailability of GP registration and contact details to medical practitioners View source Failure to share medical notes and information between private practitioners and NHS providers View source Unclear urgent and crisis referral pathways from private practitioners to NHS services View source Failure to assess NHS mental health provision independently of interim private support View source Pressure on NHS mental health services 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
Judith Maike OBHOLZER · 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
Mrs Obholzer died by suicide on 12 July 2023 after jumping in front of a moving train, following a significant period of worsening depression and anxiety. Concerns included delays in NHS mental-health assessment and waiting-list placement, unclear routes for private practitioners to obtain NHS crisis support, difficulties contacting her GP, and the absence of shared medical notes between private and NHS providers.
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 clarity in referral and crisis-support processes for patients receiving private and NHS treatment
Wider context from the report “1. In the course of the evidence it was confirmed that there is a significant pressure on NHS mental health services. It seems likely that there will be an increase in patients obtaining private support while waiting for NHS support (and often only being able to afford such support for a limited time and to a limited extent and doing so only while waiting for NHS support), as happened in this case. Consideration should be given to ensuring that there is sufficient clarity in processes such as referrals and crisis support where private practitioners are providing treatment as well as the NHS , ensuring sharing of information and notes where relevant and necessary and ensuring that the NHS provision is not assessed as unnecessary simply because someone has obtained private support as an interim measure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 GP registration and contact details to medical practitioners
Wider context from the report “3. In the course of the evidence it was confirmed that the private consultant psychiatrist was unable to send the urgent letter to Mrs Obholzer’s GP in part because their details had not been provided . Consideration should be given to ensuring that all medical practitioners (private and NHS) can access GP registration details for patients and GP contact details to avoid delays where there is an urgent need to contact a person’s GP.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 medical notes and information between private practitioners and NHS providers
Wider context from the report “4. In the course of the evidence it was confirmed that there is no sharing of medical notes between private practitioners and NHS providers . This (along with other factors) led to delays in a treatment plan being set by Wandsworth SPA as they had to obtain further details regarding Mrs Obholzer’s CBT from Mrs Obholzer rather than being able to access the notes through a shared system . Consideration should be given to ensuring a system is in place to allow the sharing of medical information between practitioners across Trusts and also between NHS and Private providers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 urgent and crisis referral pathways from private practitioners to NHS services
Wider context from the report “2. In the course of the evidence the private consultant psychiatrist gave evidence that he was unable to refer patients directly to NHS provided crisis teams as a direct alternative to informal treatment at a private hospital. The evidence from the South West London and St George’s Mental Health Trust was that direct referrals can be made although the evidence on the exact mechanism was unclear . In Mrs Obholzer’s case, the (apparent) lack of ability of the private consultant psychiatrist to directly refer to the crisis team meant that she did not receive the community crisis support alternative to hospital admission that she required. Consideration should be given to ensuring that the pathway for urgent/crisis referrals from private practitioners to the NHS are clear to all (both for this area and throughout the country) and, if it is not already the case, to ensuring a process that allows private practitioners to arrange crisis support through the NHS directly.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to assess NHS mental health provision independently of interim private support
Wider context from the report “1. In the course of the evidence it was confirmed that there is a significant pressure on NHS mental health services. It seems likely that there will be an increase in patients obtaining private support while waiting for NHS support (and often only being able to afford such support for a limited time and to a limited extent and doing so only while waiting for NHS support), as happened in this case. Consideration should be given to ensuring that there is sufficient clarity in processes such as referrals and crisis support where private practitioners are providing treatment as well as the NHS, ensuring sharing of information and notes where relevant and necessary and ensuring that the NHS provision is not assessed as unnecessary simply because someone has obtained private support as an interim measure .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Pressure on NHS mental health services
Wider context from the report “1. In the course of the evidence it was confirmed that there is a significant pressure on NHS mental health services . It seems likely that there will be an increase in patients obtaining private support while waiting for NHS support (and often only being able to afford such support for a limited time and to a limited extent and doing so only while waiting for NHS support), as happened in this case. Consideration should be given to ensuring that there is sufficient clarity in processes such as referrals and crisis support where private practitioners are providing treatment as well as the NHS, ensuring sharing of information and notes where relevant and necessary and ensuring that the NHS provision is not assessed as unnecessary simply because someone has obtained private support as an interim measure.
” 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 Recruit an additional 8,500 mental health workers to reduce treatment delays and service pressure.
Verbatim wording from the response “As part of our mission to build an NHS that is fit for the future, we will recruit an additional 8,500 mental health workers to reduce delays and provide faster treatment which will also help ease pressure on busy mental health services. To help reduce the lives lost to suicide, these new workers will be specially trained to support people at risk. More broadly, we will modernize legislation of the Mental Health Act to give greater choice, autonomy, enhanced rights and support, and ensure everyone is treated with dignity and respect throughout treatment.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for improving information sharing and reviewing the interface between NHS and non-NHS-funded independent providers.
Verbatim wording from the response “I know that NHS England has outlined to you the work they are taking forward to improve sharing of information and records overall. I understand that work is also in progress at NHS England to review the interface between NHS and non-NHS funded independent health providers, and that NHS England has offered to update you on this important work as it progresses. I assure you, I have written to NHS colleagues to ensure this is driven forward and these points are addressed.” Source location Response from DHSC
Open published response
4 Jul 2024 Harry Peter DUNN · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 2 Failure to maintain sufficient emergency ambulance resources to meet response standards View source Delays in clearing ambulances from Accident and Emergency departments 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
Harry Peter DUNN · 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
Harry Peter Dunn died shortly after arriving at hospital following a head-on collision between his motorcycle and a car on 27 August 2019. The report raised concerns about the unavailability and delayed response of ambulance resources, including delays caused by lengthy hospital handovers, and the continuing risk of future deaths from these delays.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain sufficient emergency ambulance resources to meet response standards
Wider context from the report “(1) When the 999 call was made shortly following the accident no resources were available within either the operating area of the relevant ambulance trust, East Midlands Ambulance Service Trust (“EMAS”) or within the neighbouring South Central Ambulance Service Trust . The only available emergency medical resource was that run by the Air Ambulance Service Charity which was an advanced medical team based out of Coventry Airport, some c.30 miles away with an estimated arrival time of 57 minutes.
(2) The Inquest heard that EMAS was unable to meet mean response standards at the time of the 999 call. They had entered a sustained period where demand was outstripping the resources they had available . This was worsened by the fact that what resources they did have were being delayed at hospitals due to lengthy hospital handovers at the Accident and Emergency departments.
(3) Although EMAS reported a slight improvement in the issue of resourcing following the adoption of the newer NHS Pathways triage process the delay in paramedics attending Category 2 calls has not been resolved to within target ranges . This is because EMAS’s resources cannot be fully utilised as a result of the delays in ambulances clearing Accident and Emergency departments.
(4) I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 clearing ambulances from Accident and Emergency departments
Wider context from the report “(1) When the 999 call was made shortly following the accident no resources were available within either the operating area of the relevant ambulance trust, East Midlands Ambulance Service Trust (“EMAS”) or within the neighbouring South Central Ambulance Service Trust. The only available emergency medical resource was that run by the Air Ambulance Service Charity which was an advanced medical team based out of Coventry Airport, some c.30 miles away with an estimated arrival time of 57 minutes.
(2) The Inquest heard that EMAS was unable to meet mean response standards at the time of the 999 call. They had entered a sustained period where demand was outstripping the resources they had available. This was worsened by the fact that what resources they did have were being delayed at hospitals due to lengthy hospital handovers at the Accident and Emergency departments .
(3) Although EMAS reported a slight improvement in the issue of resourcing following the adoption of the newer NHS Pathways triage process the delay in paramedics attending Category 2 calls has not been resolved to within target ranges. This is because EMAS’s resources cannot be fully utilised as a result of the delays in ambulances clearing Accident and Emergency departments .
(4) I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.
” Open source report
4 Jul 2024 David John Morris · Prevention of Future Deaths report East London
View report summary
Concerns raised 9 Poor communication in cancer diagnosis and treatment View source Failure of serious incident investigations to identify relevant reviewing clinicians View source Failure to treat and escalate suspected sepsis promptly View source Poor organisation of cancer diagnosis and treatment View source Ineffective controlled drug management systems for detecting prolonged theft and self-administration View source Failure to effectively review how deficient investigation reports gain executive approval View source Poor or absent clinical records View source Failure to identify the extent of gastrostomy leaks and onset of sepsis View source Unfit serious incident investigation reports View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David John Morris · 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
David John Morris, aged 78, developed oesophageal cancer after delays in diagnosis and treatment, later undergoing gastrostomy surgery. He developed a gastrostomy leak, peritonitis and septic shock, and died in hospital on 16 May 2022 after further surgery. The concerns included delayed recognition and treatment of the leak and sepsis, poor clinical records, deficiencies in the investigation, and ineffective controlled-drug management systems.
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 Poor communication in cancer diagnosis and treatment
Wider context from the report “1. Mr Morris’s diagnosis and treatment for cancer was delayed due to poor organisation and communication at the Trust .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of serious incident investigations to identify relevant reviewing clinicians
Wider context from the report “4. The initial serious investigation report into Mr Morris’s death was unfit for purpose. The report to investigate or even identify the Registrar who reviewed Mr Morris on the evening of 3rd May 2022 . Since then, no effective review has been undertaken by the Trust upon how this deficient report gained executive approval.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 and escalate suspected sepsis promptly
Wider context from the report “2. During the evening of 3rd May 2022 going into the early hours of 4th May 2022, Doctors and nurses failed to identify the extent of Mr Morris’s gastrostomy leak and the onset of sepsis. After identifying symptoms of sepsis, staff failed to treat and escalate Mr Morris’s case resulting in a delay of three and a half hours before a medical review commenced emergency 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 Poor organisation of cancer diagnosis and treatment
Wider context from the report “1. Mr Morris’s diagnosis and treatment for cancer was delayed due to poor organisation and communication at the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Ineffective controlled drug management systems for detecting prolonged theft and self-administration
Wider context from the report “5. The Trust did not have effective controlled drug management systems in place to detect a prolonged and persistent course of conduct from an employed nurse who was stealing and self- administering controlled drugs in the workplace .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively review how deficient investigation reports gain executive approval
Wider context from the report “4. The initial serious investigation report into Mr Morris’s death was unfit for purpose. The report to investigate or even identify the Registrar who reviewed Mr Morris on the evening of 3rd May 2022. Since then, no effective review has been undertaken by the Trust upon how this deficient report gained executive approval .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 or absent clinical records
Wider context from the report “3. During Mr Morris’s ward-based treatment on 3 & 4th May 2022 clinical records were either of a poor standard or were non-existent . The absence of clear records impeded the effective investigation of this death by the Trust’s governance teams and the Coroner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 identify the extent of gastrostomy leaks and onset of sepsis
Wider context from the report “2. During the evening of 3rd May 2022 going into the early hours of 4th May 2022, Doctors and nurses failed to identify the extent of Mr Morris’s gastrostomy leak and the onset of sepsis . After identifying symptoms of sepsis, staff failed to treat and escalate Mr Morris’s case resulting in a delay of three and a half hours before a medical review commenced emergency 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 Unfit serious incident investigation reports
Wider context from the report “4. The initial serious investigation report into Mr Morris’s death was unfit for purpose . The report to investigate or even identify the Registrar who reviewed Mr Morris on the evening of 3rd May 2022. Since then, no effective review has been undertaken by the Trust upon how this deficient report gained executive approval.
” 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 Continue working with NHS England and local systems to reduce cancer waiting times and support earlier-stage diagnosis.
Verbatim wording from the response “I wholeheartedly agree with you regarding the importance of organisations across the health system working together to ensure effective cancer diagnosis, and I regret that this did not occur in Mr Morris’ case. It is important to ensure that the issues you outlined in your report are not repeated. Thus, we will continue to work alongside NHSE and local systems to reduce waiting times and deliver on the NHS Long-Term Plan ambitions to diagnose 75% of cancers at stage 1 and 2 by 2028.” Source location 2024-0360 - Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust will respond separately to the concerns about care and processes.
Verbatim wording from the response “I understand that the Barking, Havering & Redbridge University Trust will also be responding separately to your concerns and that the London region of NHS England is” Source location 2024-0360 - Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The MHRA is best placed to address concerns about the gastrostomy device and its product information.
Verbatim wording from the response “The Chief Safety Officer at the MHRA is also providing a response to your report. And I have received assurances that they have carefully considered your concerns raised. I will not duplicate their response concerning the gastrostomy device mentioned in your report, as they are best placed to answer your concerns. As per the request from MHRA, you may wish to share the brand name and manufacturer of the gastrostomy device used on Mr Morris and MHRA will be able to check the wording in their specific product information to ensure the appropriate advice on checking for leaks is present.” Source location 2024-0360 - Response from DHSC
Open published response
Concerns raised 1 Failure to ensure availability of appropriate cannulae without supply shortages 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
Michael Trevor Walton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Trevor Walton died on 13 July 2023 after an aortic cannula became dislodged during coronary artery bypass surgery, causing prolonged interruption of blood flow to his brain and an ischaemic hypoxic brain injury. The report raised concerns that supply issues led to the use of a shorter-tip cannula, which contributed to its dislodgement, and that supply shortages may force surgeons to use sub-optimal equipment, creating an avoidable risk of serious harm or death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure availability of appropriate cannulae without supply shortages
Wider context from the report “(1) The surgeon’s preferred choice of cannula was not available for the procedure due to supply issues.
(2) A cannula with a shorter tip was therefore used for the procedure.
(3) The cannula type contributed to its dislodgement from the lumen of the aorta and to Mr Walton’s death.
(4) An arterial catheter is a basic and inexpensive medical device used daily in a hospital setting.
(5) Operating surgeons are best placed to decide on the most appropriate equipment to use and should not be restricted in that choice by supply shortages.
(6) Using sub-optimal medical equipment poses an avoidable risk to patients of significant harm including death.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the National Supply Disruption Response to help resolve escalated medical-equipment supply disruptions.
Verbatim wording from the response “The NSDR has been in place since December 2019 and acts as a single point of contact when an NHS Trust is experiencing supply disruption and has not been able to mitigate the disruption. Once a disruption has been reported to the NSDR, the Department will then work to help resolve the matter, including by:” 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 Established supply-disruption guidance, escalation processes and the National Supply Disruption Response are available to mitigate patient risks.
Verbatim wording from the response “Medical supply chains are complex, global and highly regulated, making them vulnerable to a variety of shocks. Whilst we cannot always prevent supply disruption from occurring, there are a range of well-established processes and tools in place to help manage them when they do arise, and to help mitigate risks to patients.” Source location Response from DHSC
Open published response
4 Jul 2024 Harry Peter DUNN · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1 Unavailability of nasal or buccal analgesics to paramedics 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
Harry Peter DUNN · 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
Harry Peter Dunn, aged 19, died shortly after arriving at hospital following a head-on collision between his motorcycle and a car on 27 August 2019. The report raises concern that paramedics cannot access nasal or buccal analgesics that may assist with potentially lifesaving pre-hospital treatment or faster patient extraction when time is critical.
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 nasal or buccal analgesics to paramedics
Wider context from the report “(1) As a result of the collision Mr Dunn landed in a prone position (on his front). In order for him to be treated by the pre hospital team he had to be moved out of this position to give ready access to his injuries. This necessitated the administration of analgesia. However, due to his positioning and the location of his injuries in conjunction with the extent of blood loss intravenous analgesics could not be administered.
(2) Due to the experience level and qualifications of the pre hospital team in attendance, which included a Consultant Anaesthetist, an alternative form of analgesia, namely nasal morphine could be administered.
(3) However, evidence was heard at the inquest that had the first attending team been a paramedic team they could not have administered this potentially lifesaving treatment as analgesia’s which can be delivered either nasally or buccally (via the cheek) are not presently available to paramedics despite being available to UK military personnel and mountain rescue teams.
(4) I am concerned that the unavailability of such analgesics to paramedics to assist them to deliver potentially life saving pre hospital treatments or to enable a faster extraction of a patient where time is of the essence for medical treatment reflects a risk of deaths into the future .
” 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 Take account of concerns when agreeing next steps with NHS England on expanding medicines supply, administration and prescribing responsibilities.
Verbatim wording from the response “Please be assured that we will take account of your concerns when agreeing the next steps in our joint work programme with NHSE regarding expanding supply, administration and prescribing of medicines responsibilities for regulated healthcare professionals.” Source location Response-from-DHSC
Open published response
27 Jun 2024 Emily Rose Collishaw · Prevention of Future Deaths report Outer South London
View report summary
Concerns raised 3 Delays in organizations agreeing their roles View source Insufficient support to maintain physical health and promote abstinence View source Delays in accessing residential rehabilitation care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Emily Rose Collishaw · 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
Emily Rose Collishaw, who was aged 35, was found dead in her flat on 6 September 2023 in non-suspicious circumstances. She had alcohol dependency and had been receiving mental health and substance misuse support, but was awaiting an inpatient rehabilitation placement. Concerns included delays and insufficient coordination and support, particularly the prolonged wait for residential rehabilitation and the associated risks to patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in organizations agreeing their roles
Wider context from the report “1. Emily’s mother reported that it took some time for the organizations working with her daughter to agree their roles and that the degree of support was insufficient to maintain her physical health or promote abstinence over such a long period of six months before she died. The family felt that the referral for residential care should have been made earlier, especially as her housing situation was a risk to her health. It was accepted that Emily did not engage consistently but did reduce intake on a number of occasions, only to relapse.
2. The inquest heard from professionals that the period of waiting for a residential rehabilitation placement was about three months, but could be as long as seven months. Evidence was heard from the manager of the Pier Project that the delay in accessing residential care had been progressively getting longer over the last 10 years, which posed risks such as sudden death to patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient support to maintain physical health and promote abstinence
Wider context from the report “1. Emily’s mother reported that it took some time for the organizations working with her daughter to agree their roles and that the degree of support was insufficient to maintain her physical health or promote abstinence over such a long period of six months before she died. The family felt that the referral for residential care should have been made earlier, especially as her housing situation was a risk to her health. It was accepted that Emily did not engage consistently but did reduce intake on a number of occasions, only to relapse.
2. The inquest heard from professionals that the period of waiting for a residential rehabilitation placement was about three months, but could be as long as seven months. Evidence was heard from the manager of the Pier Project that the delay in accessing residential care had been progressively getting longer over the last 10 years, which posed risks such as sudden death to patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in accessing residential rehabilitation care
Wider context from the report “1. Emily’s mother reported that it took some time for the organizations working with her daughter to agree their roles and that the degree of support was insufficient to maintain her physical health or promote abstinence over such a long period of six months before she died. The family felt that the referral for residential care should have been made earlier, especially as her housing situation was a risk to her health. It was accepted that Emily did not engage consistently but did reduce intake on a number of occasions, only to relapse.
2. The inquest heard from professionals that the period of waiting for a residential rehabilitation placement was about three months, but could be as long as seven months . Evidence was heard from the manager of the Pier Project that the delay in accessing residential care had been progressively getting longer over the last 10 years , which posed risks such as sudden death to patients.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish further guidance for local areas on improving access to residential rehabilitation.
Verbatim wording from the response “I am aware of variability across the country in access to inpatient detoxification and/or residential rehabilitation. To address this (as part of the increased funding provided since 2022/2023), combinations of ring-fenced funding, targets, additional guidance and targeted support have been used to improve capacity and quality of inpatient detoxification and residential rehabilitation. We also plan to publish further guidance for local areas on improving access to residential rehabilitation later this year.” 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 joint work to improve integrated and coordinated care for people with co-occurring mental health and alcohol or drug use conditions.
Verbatim wording from the response “We do, though, recognise that improvement is still needed across England, and OHID and NHSE will continue to work closely together to improve integrated and co-ordinated care for people with comorbidities, including co-occurring mental health conditions and alcohol and drug use conditions.” 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 Establish the PanLondon Inpatient Detoxification Programme and open an 11-bed unit at St Thomas’ Hospital.
Verbatim wording from the response “In London in 2021, following the steady closure of the city’s inpatient detoxification units due to increasing costs and an unsustainable spot purchase funding model, the PanLondon Inpatient Detoxification Programme was established to address the issue and an 11-bed unit in St Thomas’ hospital was opened. The unit provides a high level of care for a small cohort of people with complex needs. Work is currently underway, led by the London Regional Team of the Office for Health Improvement and Disparities (OHID) to further develop sustainable inpatient detoxification provision in London.” 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 Further develop sustainable inpatient detoxification provision in London.
Verbatim wording from the response “In London in 2021, following the steady closure of the city’s inpatient detoxification units due to increasing costs and an unsustainable spot purchase funding model, the PanLondon Inpatient Detoxification Programme was established to address the issue and an 11-bed unit in St Thomas’ hospital was opened. The unit provides a high level of care for a small cohort of people with complex needs. Work is currently underway, led by the London Regional Team of the Office for Health Improvement and Disparities (OHID) to further develop sustainable inpatient detoxification provision in London.” 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 Provide ring-fenced funding, targets, guidance and targeted support to improve inpatient detoxification and residential rehabilitation capacity and quality.
Verbatim wording from the response “My department recognises the need to improve specialist drug and alcohol treatment services. Additional funding has been available since 2022/23 for local authorities to improve the quality and capacity of drug and alcohol treatment, including inpatient detoxification and residential rehabilitation services, and an additional £266.7 million was made available to them this year.” 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 Local alcohol and drug treatment services are expected to minimise placement delays, support people awaiting care, and regularly review their needs.
Verbatim wording from the response “At a local level we would expect alcohol and drug treatment services to do what they can to minimise delays in accessing inpatient detoxification and residential rehabilitation, provide individual support to anyone waiting for it, and to regularly review their needs. The UK Clinical guidelines on alcohol treatment (to be published later this year) will include recommendations to promote this good practice.” Source location Response from DHSC
Open published response
26 Jun 2024 Raymond Horace Watkins · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Lack of Time Critical Medicine guidance for the community setting View source Failure to ensure receipt of correct medicine authorisations by District Nurses 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
Raymond Horace Watkins · 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
Raymond Horace Watkins was admitted to hospital, discharged to his care home after his insulin and other medications had been stopped, and subsequently sought to restart them. Administrative errors meant the insulin prescription was not authorised before his readmission, although expert evidence concluded that prescribing insulin would not have been appropriate in this case and would not have changed the outcome. The substantive concern was a breakdown in communication between the GP and District Nurses, alongside the lack of “Time Critical Medicine” guidance for community settings.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of Time Critical Medicine guidance for the community setting
Wider context from the report “1. During the course of the evidence the court heard that receipt of correct authorisations in respect of medicines is an issue faced by District Nurses in many areas of the country.
Currently there is no “Time Critical Medicine” guidance for the community setting.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure receipt of correct medicine authorisations by District Nurses
Wider context from the report “1. During the course of the evidence the court heard that receipt of correct authorisations in respect of medicines is an issue faced by District Nurses in many areas of the country .
Currently there is no “Time Critical Medicine” guidance for the community setting.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for addressing community prescribing and time-critical medicines guidance rests with NHS England.
Verbatim wording from the response “• During the course of the evidence the court heard that receipt of correct authorisations in respect of medicines is an issue faced by District Nurses in many areas of the country. Currently there is no “Time Critical Medicine” guidance for the community setting.” Source location Response from DHSC
Open published response
Concerns raised 2 Failure of window restrictor standards to address deliberate attempts to defeat restrictors View source Lack of reliable, up-to-date guidance on the limitations of window restrictor standards View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Terrence Roy Hubert 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
Terrence Roy Hubert Taylor, an 82-year-old short-term resident of a residential care home, overcame a window restrictor, climbed out of a first-floor window and fell during the early hours of 11 December 2020, sustaining injuries from which he died. The principal concern was that current British Standards for window restrictors address accidental falls but not deliberate attempts to defeat them, and that this limitation and subsequent guidance on stronger restrictors were not generally known or understood by residential care home operators, manufacturers or suppliers.
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 window restrictor standards to address deliberate attempts to defeat restrictors
Wider context from the report “1. The concern relates to the guidance provided to operators of residential care homes in respect of window restrictors and the standard they are required to meet. The current standards have been developed to prevent accidental falling from windows. They do not deal with deliberate attempts to defeat the restrictor , which may well be the situation encountered residential care homes, as in fact occurred in this case. This limitation is not known or understood by operators of residential care homes.
2. In December 2013 the Department of Health published Health Building Note 00-10 Part D: Windows and associated hardware. That guidance was not directed to residential care home provides. The Guidance was updated following an earlier Coroner’s report to prevent future deaths addressed to the Chief Medical Officer. That Guidance Note provides that
“... window restrictors tested to current British Standards may be inadequate in preventing a determined effort to force a window open beyond 100mm ...”.
It also noted that:
“... The relevant tests for restrictors cited in BS EN 14351-1 and BS EN 13126-5 have been developed to prevent accidental falling from windows ... None of the British and European Standards deal with deliberate attempts to defeat the restrictor using impact forces , which may be the situation encountered in hospitals and care homes”.
3. The evidence was that this Guidance was not generally known or understood by operators of residential care homes or manufactures or suppliers of window restrictors.
4. In 2019 the Health and Safety Executive published Research Report RR1150 Review of Window Restrictors use in Health and Social Care. The outcome of that research was that in order to protect vulnerable people in health and social care premises:
“... it is suggested that window restrictors (and their fixings) are capable of withstanding push forces of at least 850N ...”.
5. Thus the HSE’s research suggests that window restrictors in health and social care premises should be able to withstand forces very much greater than that of the British Standards .
6. The evidence was that this research was not generally known or understood by operators of residential care homes or manufactures or suppliers of window restrictors.
7. Operators of care homes are likely to consider they are taking reasonable steps to secure windows by fitting restrictors that meet the British Standards, whereas the 2013 Department of Health Guidance and the 2019 Health and Safety Executive research indicates that is not so.
8. Action is required to ensure operators of care homes are provided with reliable, up to date guidance and to ensure that the limitations of the British Standard are widely known and understood by operators of residential care homes.
9. Action is required to review the British Standard relating to window restrictors to consider whether some different standard or qualification to the existing standard is required in respect of residential care homes and/or deliberate acts to disable window restrictors.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 reliable, up-to-date guidance on the limitations of window restrictor standards
Wider context from the report “1. The concern relates to the guidance provided to operators of residential care homes in respect of window restrictors and the standard they are required to meet. The current standards have been developed to prevent accidental falling from windows. They do not deal with deliberate attempts to defeat the restrictor, which may well be the situation encountered residential care homes, as in fact occurred in this case. This limitation is not known or understood by operators of residential care homes .
2. In December 2013 the Department of Health published Health Building Note 00-10 Part D: Windows and associated hardware. That guidance was not directed to residential care home provides . The Guidance was updated following an earlier Coroner’s report to prevent future deaths addressed to the Chief Medical Officer. That Guidance Note provides that
“... window restrictors tested to current British Standards may be inadequate in preventing a determined effort to force a window open beyond 100mm ...”.
It also noted that:
“... The relevant tests for restrictors cited in BS EN 14351-1 and BS EN 13126-5 have been developed to prevent accidental falling from windows ... None of the British and European Standards deal with deliberate attempts to defeat the restrictor using impact forces, which may be the situation encountered in hospitals and care homes”.
3. The evidence was that this Guidance was not generally known or understood by operators of residential care homes or manufactures or suppliers of window restrictors .
4. In 2019 the Health and Safety Executive published Research Report RR1150 Review of Window Restrictors use in Health and Social Care. The outcome of that research was that in order to protect vulnerable people in health and social care premises:
“... it is suggested that window restrictors (and their fixings) are capable of withstanding push forces of at least 850N ...”.
5. Thus the HSE’s research suggests that window restrictors in health and social care premises should be able to withstand forces very much greater than that of the British Standards.
6. The evidence was that this research was not generally known or understood by operators of residential care homes or manufactures or suppliers of window restrictors .
7. Operators of care homes are likely to consider they are taking reasonable steps to secure windows by fitting restrictors that meet the British Standards, whereas the 2013 Department of Health Guidance and the 2019 Health and Safety Executive research indicates that is not so.
8. Action is required to ensure operators of care homes are provided with reliable, up to date guidance and to ensure that the limitations of the British Standard are widely known and understood by operators of residential care homes.
9. Action is required to review the British Standard relating to window restrictors to consider whether some different standard or qualification to the existing standard is required in respect of residential care homes and/or deliberate acts to disable window restrictors.
” 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 Contact the Health and Safety Executive about reviewing the British Standard for window restrictors.
Verbatim wording from the response “In response to your second request for action, reviewing the British Standard is not within the scope of my Department's responsibilities. However, my officials have contacted HSE on this matter and await their reply.” 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 Reviewing the British Standard for window restrictors is outside the Department’s responsibilities.
Verbatim wording from the response “In response to your second request for action, reviewing the British Standard is not within the scope of my Department's responsibilities. However, my officials have contacted HSE on this matter and await their reply.” 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 CQC will address raising awareness of current window-restrictor guidance among residential care home operators.
Verbatim wording from the response “In response to your first request, CQC are a named responder to this case. CQC’s separate response will address concerns related to raising awareness amongst residential care home operators of the latest guidance on window restrictors.” Source location Response from DHSC
Open published response
14 Jun 2024 Amina Ahmed Ismail · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 8 National scarcity of specialist personality-disorder rehabilitation beds View source Variation in admission criteria and exclusions across specialist personality-disorder rehabilitation units View source Underfunding of local mental health beds View source Over-reliance by the NHS on independent mental health-bed providers View source Delays in transferring patients from out-of-area independent-provider hospitals View source Funding allocation failing to secure available specialist rehabilitation beds for identified patients View source Home teams’ inability to commission or make funding decisions for specialist personality-disorder placements View source Delays in funding approval for specialist rehabilitation beds View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Amina Ahmed Ismail · 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
Amina Ahmed Ismail, aged 19, died on 15 September 2023 at Pankhurst Ward, Priory Hospital Cheadle, after self-ligaturing; the medical cause of death was ligature strangulation. The report describes her prolonged stay in a PICU, deterioration in her mental health, shortages of appropriate specialist care beds, and delays in arranging and funding a suitable placement as concerns contributing to the circumstances of her death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation National scarcity of specialist personality-disorder rehabilitation beds
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds , paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally ’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units. These are commissioned/funded directly by the ICB upon application by the FTB; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months. In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it. The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding.
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Variation in admission criteria and exclusions across specialist personality-disorder rehabilitation units
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding ’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units. These are commissioned/funded directly by the ICB upon application by the FTB; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months. In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it. The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding.
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Underfunding of local mental health beds
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units. These are commissioned/funded directly by the ICB upon application by the FTB; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months. In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it. The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding.
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Over-reliance by the NHS on independent mental health-bed providers
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units. These are commissioned/funded directly by the ICB upon application by the FTB; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months. In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it. The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding.
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 transferring patients from out-of-area independent-provider hospitals
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units ; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units. These are commissioned/funded directly by the ICB upon application by the FTB; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months. In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it. The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding.
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Funding allocation failing to secure available specialist rehabilitation beds for identified patients
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units. These are commissioned/funded directly by the ICB upon application by the FTB; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months. In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it . The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding .
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Home teams’ inability to commission or make funding decisions for specialist personality-disorder placements
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units . These are commissioned/funded directly by the ICB upon application by the FTB ; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months. In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it. The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding.
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 funding approval for specialist rehabilitation beds
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units. These are commissioned/funded directly by the ICB upon application by the FTB; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate ; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months . In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it. The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding.
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with the NHS to maximise mental health service capacity.
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 understand that mental health services have been under significant strain in recent years due to the rise in demand and the Department will continue to work with the NHS to maximise capacity.” 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 Integrated care boards are responsible for developing three-year plans to localise and realign inpatient mental health care, including independent-sector provision.
Verbatim wording from the response “In 2022 NHS England launched the mental health, learning disability and autism inpatient quality transformation programme. A core aim of the programme is to localise and realign care, harnessing the potential of people and communities. The programme is built upon the cornerstones of good mental healthcare; continuity of care, therapeutic relationships and a commitment to mental health care meeting the needs of the population. All integrated care boards have been tasked by NHS England with developing 3-year plans to localise and realign inpatient mental health care, including NHS-funded care provided by the independent sector, as part of this programme.” 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 bed capacity, patient flow and specialist rehabilitation-unit 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 understand that mental health services have been under significant strain in recent years due to the rise in demand and the Department will continue to work with the NHS to maximise capacity.” Source location Response from DHSC
Open published response
11 Jun 2024 Juan David Martin · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1 Inadequate mental health bed capacity in London View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Juan David Martin · 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
Juan David Martin, who had been detained under the Mental Health Act and was awaiting an appropriate mental health bed, was evacuated from a hospital assessment suite during a fire alarm and ran away. He was later witnessed allowing himself to fall from height and was confirmed deceased on 13 April 2022. The principal concern was that inadequate mental health bed capacity in London created a genuine risk of future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate mental health bed capacity in London
Wider context from the report “(1) Juan Martin was held informally on 7 April 2022 and following a mental health assessment on 11 April subsequently became liable for detention. He therefore spent 6 days in the Lotus Assessment Suite. Witnesses confirmed that no suitable bed was identified until approximately after 15:00 on 12 April 2022, which then became unavailable.
(2) The Matron in Acute and Urgent Care confirmed bed capacity remains an ongoing problem and has not been resolved . The Matron provided one recent example where a patient waited for 7 days in the Accident and Emergency Department for a mental health bed .
(3) The Matron added there was an exceptional process which required a considered decision at a high level to make a bed available through identifying someone currently occupying a bed space to be discharged and that the ‘flow’ of patients being discharged or moving to another setting amplified the bed capacity issue.
Based on the evidence heard, my principal concern is that bed capacity in London remains inadequate . Whilst some action may have been taken by the Trust to better triage the need for beds it is insufficient to resolve the problem . It follows there is a genuine risk of future deaths directly connected to a shortage of mental health bed spaces in London unless further action is taken.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver mental health care in the community through new models of care and support wherever possible.
Verbatim wording from the response “At national level, as part of our mission to build an NHS fit for the future, we will make sure mental health care is delivered in the community wherever possible - through new models of care and support available for those who are struggling - so that more people are prevented from needing 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 Local mental health bed capacity and patient flow concerns are assigned to the relevant NHS Trust and Integrated Care Board.
Verbatim wording from the response “I understand that South West London and St George’s Mental Health NHS Trust and NHS South West London Integrated Care Board will respond to your concerns about local mental health bed capacity directly, reflecting their responsibility to assess bed capacity and the ‘flow’ of patients being discharged or moving to another setting.” Source location Response from DHSC
Open published response
10 Jun 2024 Sailor (previously known as Sara) COURT · Prevention of Future Deaths report South London
View report summary
Concerns raised 4 Insufficient capacity to safely assess and re-prioritise urgent CAMHS waiting-list patients View source Delays in CAMHS treatment View source Delays in CAMHS assessment View source Lack of CAMHS resources keeping pace with increasing demand View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sailor (previously known as Sara) COURT · 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
Sailor (previously known as Sara) COURT, aged 14, died by suicide on 17 September 2021 after taking an overdose at home while on the CAMHS waiting list for treatment. The principal concerns were unacceptably long waits for assessment and treatment, which had not improved and were attributed to insufficient resources relative to demand.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity to safely assess and re-prioritise urgent CAMHS waiting-list patients
Wider context from the report “(1) The anticipated waiting times before Sailor’s assessment (approximately one year) was unacceptably long.
(2) The length of time before treatment could be delivered thereafter (approximately 10 months) was unacceptably long.
(3) The Court heard evidence that the waiting times for assessment and treatment have not improved since Sailor’s death, and in fact both have significantly increased. This means that a teenager referred today into the CAMHS could be waiting for around / upwards of two years before they receive treatment. This is an unacceptably long delay.
(4) The Court heard evidence that the Trust is attempting to mitigate the problem by way of a proactive “Keeping in Touch” team with the potential to streamline / re-organise the waiting list. However, due to the number of individuals on the waiting list (estimated to be over 1,000) and the number of staff engaged in the Keeping in Touch team (three) and the scale of the task, I was not re-assured that the Keeping in Touch team could realistically and / or safely assess or re-prioritise those on the waiting list in most urgent need of assessment or treatment .
(5) The Court heard evidence that the long waiting lists were a result of a lack of resources which has not kept pace with significantly increased (and increasing) demand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 CAMHS treatment
Wider context from the report “(1) The anticipated waiting times before Sailor’s assessment (approximately one year) was unacceptably long.
(2) The length of time before treatment could be delivered thereafter (approximately 10 months) was unacceptably long.
(3) The Court heard evidence that the waiting times for assessment and treatment have not improved since Sailor’s death, and in fact both have significantly increased. This means that a teenager referred today into the CAMHS could be waiting for around / upwards of two years before they receive treatment . This is an unacceptably long delay.
(4) The Court heard evidence that the Trust is attempting to mitigate the problem by way of a proactive “Keeping in Touch” team with the potential to streamline / re-organise the waiting list. However, due to the number of individuals on the waiting list (estimated to be over 1,000) and the number of staff engaged in the Keeping in Touch team (three) and the scale of the task, I was not re-assured that the Keeping in Touch team could realistically and / or safely assess or re-prioritise those on the waiting list in most urgent need of assessment or treatment.
(5) The Court heard evidence that the long waiting lists were a result of a lack of resources which has not kept pace with significantly increased (and increasing) demand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 CAMHS assessment
Wider context from the report “(1) The anticipated waiting times before Sailor’s assessment (approximately one year) was unacceptably long.
(2) The length of time before treatment could be delivered thereafter (approximately 10 months) was unacceptably long.
(3) The Court heard evidence that the waiting times for assessment and treatment have not improved since Sailor’s death, and in fact both have significantly increased. This means that a teenager referred today into the CAMHS could be waiting for around / upwards of two years before they receive treatment . This is an unacceptably long delay.
(4) The Court heard evidence that the Trust is attempting to mitigate the problem by way of a proactive “Keeping in Touch” team with the potential to streamline / re-organise the waiting list. However, due to the number of individuals on the waiting list (estimated to be over 1,000) and the number of staff engaged in the Keeping in Touch team (three) and the scale of the task, I was not re-assured that the Keeping in Touch team could realistically and / or safely assess or re-prioritise those on the waiting list in most urgent need of assessment or treatment.
(5) The Court heard evidence that the long waiting lists were a result of a lack of resources which has not kept pace with significantly increased (and increasing) demand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 CAMHS resources keeping pace with increasing demand
Wider context from the report “(1) The anticipated waiting times before Sailor’s assessment (approximately one year) was unacceptably long.
(2) The length of time before treatment could be delivered thereafter (approximately 10 months) was unacceptably long.
(3) The Court heard evidence that the waiting times for assessment and treatment have not improved since Sailor’s death, and in fact both have significantly increased. This means that a teenager referred today into the CAMHS could be waiting for around / upwards of two years before they receive treatment. This is an unacceptably long delay.
(4) The Court heard evidence that the Trust is attempting to mitigate the problem by way of a proactive “Keeping in Touch” team with the potential to streamline / re-organise the waiting list. However, due to the number of individuals on the waiting list (estimated to be over 1,000) and the number of staff engaged in the Keeping in Touch team (three) and the scale of the task, I was not re-assured that the Keeping in Touch team could realistically and / or safely assess or re-prioritise those on the waiting list in most urgent need of assessment or treatment.
(5) The Court heard evidence that the long waiting lists were a result of a lack of resources which has not kept pace with significantly increased (and increasing) demand .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit 8,500 additional staff across children’s and adult mental health services.
Verbatim wording from the response “As part of our mission to build an NHS that is fit for the future and that serves the patients that need it, this Government will recruit 8,500 additional staff across children’s and adult mental health services, introduce a specialist mental health professional in every school and roll out Young Futures hubs in every community to intervene earlier with more timely mental health support.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England will address concerns about the keeping in touch team in its response to the report.
Verbatim wording from the response “With regards to your concerns about the “keeping in touch team” at South London and Maudsley NHS Foundation Trust. I have been in touch with Stephen Powis at NHS England to discuss the service. I understand that colleagues at NHS England will address these concerns in more detail in its response to your report.” 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