9 Dec 2025 Hannah Louise Booth · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 4 Failure to record or cross-reference information relevant to both mother and baby in both records View source Lack of a single electronic patient record accessible to all services View source Lack of shared policies, guidance and understanding about information relevant for sharing between services View source Failure to escalate and share increasing contact with health visitors with perinatal mental health services 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
Hannah Louise Booth · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Hannah Louise Booth, who had been diagnosed with post-natal depression after giving birth in July 2024, drowned in the Goyt River on 6 January 2025 after sending a message evidencing her intention to take her own life. The report identified concerns about information sharing between services, including different record systems, incomplete records, and relevant information about Hannah being recorded only in her baby’s records. Increasing contact about her baby’s development was not shared with perinatal mental health services or recognised as potentially indicating that Hannah was struggling.
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 Derbyshire Community Health Services NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record or cross-reference information relevant to both mother and baby in both records
Wider context from the report “This inquest has exposed important issues with information sharing between services and also within services. Those issues are:
• Difficulties encountered because different IT systems were being used for record keeping in different services. Essentially a lack of a single patient record.
• A lack of a shared understanding of what is relevant information and needs to be made available to other services.
• Relevant notes being made in records of baby and not repeated in notes of the mum.
Further detail:
1. Sett Valley, the health visitors and perinatal mental health services all had information about Hannah that was potentially relevant to her mental health, but none had the whole picture. It was evident that had those within the perinatal mental health services known about Hannah’s increasing frequency of contact with services about her baby’s development, it would have prompted further contact by them with Hannah and prompted a review of risk and support offered. They did not know and there was no further contact.
2. There was no single electronic patient record accessible to all services. Whilst the perinatal mental health and health visitors used SystmOne, Sett Valley did not. The health visitor had not informed Sett Valley about the contact Hannah had had with them on 27th December so that the GP seeing Hannah on 31st did not know that Hannah was beginning to make increased contact with services about her concerns and did not share any information about that consultation with other services.
3. There was increasing contact with health visitors that was not escalated to or shared with perinatal mental health. The significance of the increased contact, to Hannah’s mental health, did not appear to have been understood. The concerns raised at each contact around her baby’s development were dealt with at face value with exploration and examination of her baby’s development and reassurances given to Hannah regarding the particular concerns raised. The evidence revealed that it was not the individual concerns raised that were relevant to Hannah’s mental health but the fact that she was making more frequent contact which suggested she was struggling. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when.
4. Within both Sett Valley and health visitor records there was potentially important information relevant to Hannah’s mental health recorded only within her baby’s records. At any future appointments concerning Hannah the relevant medical history available on her record would have been incomplete. It also meant that whilst the perinatal mental health services had access to the health visitor notes in relation to Hannah (because they both used SystmOne), even had they had cause to look at Hannah’s notes they would still not have had all relevant information. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records or cross referenced. This appears to be particularly important in the perinatal period.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Derbyshire Community Health Services NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a single electronic patient record accessible to all services
Wider context from the report “This inquest has exposed important issues with information sharing between services and also within services. Those issues are:
• Difficulties encountered because different IT systems were being used for record keeping in different services. Essentially a lack of a single patient record.
• A lack of a shared understanding of what is relevant information and needs to be made available to other services.
• Relevant notes being made in records of baby and not repeated in notes of the mum.
Further detail:
1. Sett Valley, the health visitors and perinatal mental health services all had information about Hannah that was potentially relevant to her mental health, but none had the whole picture. It was evident that had those within the perinatal mental health services known about Hannah’s increasing frequency of contact with services about her baby’s development, it would have prompted further contact by them with Hannah and prompted a review of risk and support offered. They did not know and there was no further contact.
2. There was no single electronic patient record accessible to all services. Whilst the perinatal mental health and health visitors used SystmOne, Sett Valley did not. The health visitor had not informed Sett Valley about the contact Hannah had had with them on 27th December so that the GP seeing Hannah on 31st did not know that Hannah was beginning to make increased contact with services about her concerns and did not share any information about that consultation with other services.
3. There was increasing contact with health visitors that was not escalated to or shared with perinatal mental health. The significance of the increased contact, to Hannah’s mental health, did not appear to have been understood. The concerns raised at each contact around her baby’s development were dealt with at face value with exploration and examination of her baby’s development and reassurances given to Hannah regarding the particular concerns raised. The evidence revealed that it was not the individual concerns raised that were relevant to Hannah’s mental health but the fact that she was making more frequent contact which suggested she was struggling. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when.
4. Within both Sett Valley and health visitor records there was potentially important information relevant to Hannah’s mental health recorded only within her baby’s records. At any future appointments concerning Hannah the relevant medical history available on her record would have been incomplete. It also meant that whilst the perinatal mental health services had access to the health visitor notes in relation to Hannah (because they both used SystmOne), even had they had cause to look at Hannah’s notes they would still not have had all relevant information. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records or cross referenced. This appears to be particularly important in the perinatal period.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Derbyshire Community Health Services NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of shared policies, guidance and understanding about information relevant for sharing between services
Wider context from the report “This inquest has exposed important issues with information sharing between services and also within services. Those issues are:
• Difficulties encountered because different IT systems were being used for record keeping in different services. Essentially a lack of a single patient record.
• A lack of a shared understanding of what is relevant information and needs to be made available to other services.
• Relevant notes being made in records of baby and not repeated in notes of the mum.
Further detail:
1. Sett Valley, the health visitors and perinatal mental health services all had information about Hannah that was potentially relevant to her mental health, but none had the whole picture. It was evident that had those within the perinatal mental health services known about Hannah’s increasing frequency of contact with services about her baby’s development, it would have prompted further contact by them with Hannah and prompted a review of risk and support offered. They did not know and there was no further contact.
2. There was no single electronic patient record accessible to all services. Whilst the perinatal mental health and health visitors used SystmOne, Sett Valley did not. The health visitor had not informed Sett Valley about the contact Hannah had had with them on 27th December so that the GP seeing Hannah on 31st did not know that Hannah was beginning to make increased contact with services about her concerns and did not share any information about that consultation with other services.
3. There was increasing contact with health visitors that was not escalated to or shared with perinatal mental health. The significance of the increased contact, to Hannah’s mental health, did not appear to have been understood. The concerns raised at each contact around her baby’s development were dealt with at face value with exploration and examination of her baby’s development and reassurances given to Hannah regarding the particular concerns raised. The evidence revealed that it was not the individual concerns raised that were relevant to Hannah’s mental health but the fact that she was making more frequent contact which suggested she was struggling. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when.
4. Within both Sett Valley and health visitor records there was potentially important information relevant to Hannah’s mental health recorded only within her baby’s records. At any future appointments concerning Hannah the relevant medical history available on her record would have been incomplete. It also meant that whilst the perinatal mental health services had access to the health visitor notes in relation to Hannah (because they both used SystmOne), even had they had cause to look at Hannah’s notes they would still not have had all relevant information. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records or cross referenced. This appears to be particularly important in the perinatal period.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Derbyshire Community Health Services NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate and share increasing contact with health visitors with perinatal mental health services
Wider context from the report “This inquest has exposed important issues with information sharing between services and also within services. Those issues are:
• Difficulties encountered because different IT systems were being used for record keeping in different services. Essentially a lack of a single patient record.
• A lack of a shared understanding of what is relevant information and needs to be made available to other services.
• Relevant notes being made in records of baby and not repeated in notes of the mum.
Further detail:
1. Sett Valley, the health visitors and perinatal mental health services all had information about Hannah that was potentially relevant to her mental health, but none had the whole picture. It was evident that had those within the perinatal mental health services known about Hannah’s increasing frequency of contact with services about her baby’s development, it would have prompted further contact by them with Hannah and prompted a review of risk and support offered. They did not know and there was no further contact.
2. There was no single electronic patient record accessible to all services. Whilst the perinatal mental health and health visitors used SystmOne, Sett Valley did not. The health visitor had not informed Sett Valley about the contact Hannah had had with them on 27th December so that the GP seeing Hannah on 31st did not know that Hannah was beginning to make increased contact with services about her concerns and did not share any information about that consultation with other services.
3. There was increasing contact with health visitors that was not escalated to or shared with perinatal mental health. The significance of the increased contact, to Hannah’s mental health, did not appear to have been understood. The concerns raised at each contact around her baby’s development were dealt with at face value with exploration and examination of her baby’s development and reassurances given to Hannah regarding the particular concerns raised. The evidence revealed that it was not the individual concerns raised that were relevant to Hannah’s mental health but the fact that she was making more frequent contact which suggested she was struggling. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when.
4. Within both Sett Valley and health visitor records there was potentially important information relevant to Hannah’s mental health recorded only within her baby’s records. At any future appointments concerning Hannah the relevant medical history available on her record would have been incomplete. It also meant that whilst the perinatal mental health services had access to the health visitor notes in relation to Hannah (because they both used SystmOne), even had they had cause to look at Hannah’s notes they would still not have had all relevant information. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records or cross referenced. This appears to be particularly important in the perinatal period.
” 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 Document telephone advice-line discussions in the relevant parent’s health record when information concerns parental mental health.
Verbatim wording from the response “It has also been agreed that advice line discussion will take place via telephone and that these conversations should be documented within the mother/father’s health record, rather than child record, where the information relates specifically to parental mental health (for both services).” Source location Response from Derbyshire Community Health Service NHS Foundation Trust
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 Reinforce parental-record documentation standards through staff training and supervision.
Verbatim wording from the response “Locality Managers have been briefed on the findings of the inquest and the learning identified. Strengthening documentation within parental records has been identified as” Source location Response from Derbyshire Community Health Service NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the Perinatal Mental Health Service advice line for consultation and proactively share relevant contextual information about patients already receiving its care.
Verbatim wording from the response “During this meeting, it was agreed that the Perinatal Mental Health Service should be utilised by the Health Visiting Service as an advice and consultation resource, in addition to the existing formal referral pathways. Health Visitors are able to contact the Perinatal Mental Health Service advice line to discuss concerns, seek professional advice, or share relevant information without the need to submit a formal referral.” Source location Response from Derbyshire Community Health Service NHS Foundation Trust
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 Update Health Visiting Service standard operating procedures to formalize information-sharing expectations and use of the Perinatal Mental Health Service advice line.
Verbatim wording from the response “As a result of this discussion, the Health Visiting Service is in the process of updating its Standard Operating Procedures to reflect the agreed approach to information sharing and the use of the Perinatal Mental Health Service advice line. This update will provide clear, consistent guidance to staff and reinforce expectations regarding early consultation and sharing of relevant information.” Source location Response from Derbyshire Community Health Service NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the SystmOne auto-consultation function to create parent-record entries referencing relevant information from child contacts.
Verbatim wording from the response “To support this in practice, an auto-consultation function has been implemented within SystmOne. This functionality enables clinicians to promptly create an entry within the parent’s record that references relevant information arising from a child contact, supporting consistent and timely documentation and strengthening the visibility of parental mental health information.” Source location Response from Derbyshire Community Health Service NHS Foundation Trust
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 Incorporate documentation and cross-referencing guidance into the Trust’s Perinatal Mental Health standard operating procedure.
Verbatim wording from the response “Best practice guidance on documentation and cross-referencing between child and parent records will be formally incorporated into the Trust’s Perinatal Mental Health Standard Operating Procedure. This will provide clear, consistent guidance and support improved documentation standards.” Source location Response from Derbyshire Community Health Service NHS Foundation Trust
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 Require staff to cross-reference relevant parental mental-health information in both child and parent records.
Verbatim wording from the response “The Health Visiting Service recognises the importance of clear and accurate documentation to ensure that relevant information is accessible to all professionals involved in family care. The established principle remains that information relating to a parent’s mental health should be documented within the specific parent’s health record, while information relating specifically to the child should be recorded in the child’s record.” Source location Response from Derbyshire Community Health Service NHS Foundation Trust
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 Share a one-page document with all staff clarifying expected record-keeping standards for parental mental health.
Verbatim wording from the response “A one-page document clarifying the expected standard of record keeping about parental mental health has been shared with all staff via team meetings, which took place during the week commencing 26th January 2026. Further information will be shared with all staff when the perinatal mental health team infographic is available to disseminate.” Source location Response from Derbyshire Community Health Service NHS Foundation Trust
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 and circulate an infographic explaining the advice line, appropriate use, and information to share, with practical examples for Health Visiting staff.
Verbatim wording from the response “To support clarity and consistency in practice, the Perinatal Mental Health Service has agreed to develop an infographic for Health Visiting staff. This will provide clear, accessible guidance on:” Source location Response from Derbyshire Community Health Service NHS Foundation Trust
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 Resolving the absence of a unified patient record requires system-wide and national action overseen by NHS England, rather than action by an individual Trust.
Verbatim wording from the response “The Trust notes that the absence of a single, unified patient record across all NHS and GP settings is a longstanding national issue, overseen by NHS England. Any substantive resolution to this issue would require system-wide and national action, rather than action by an individual NHS Trust.” Source location Response from Derbyshire Community Health Service NHS Foundation Trust
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 Configuration and interoperability of clinical record systems across NHS providers and GP practices fall outside the Trust’s direct control and remit.
Verbatim wording from the response “The Trust acknowledges that variations in clinical IT systems across NHS organisations can present challenges to the timely sharing of patient information. However, the configuration, interoperability and alignment of clinical record systems across NHS providers and GP practices are determined at a national and system level and sit outside the direct control and remit of the Trust.” Source location Response from Derbyshire Community Health Service NHS Foundation Trust
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 universal health visiting, professional communication, GP liaison and record-access arrangements address local information-sharing needs despite the absence of a single record.
Verbatim wording from the response “Notwithstanding these system-level constraints, the Trust has robust arrangements in place to ensure that children and young people receive universal health visiting services, and GP practices are aware of and able to engage with those services.” Source location Response from Derbyshire Community Health Service NHS Foundation Trust
Open published response
9 Jun 2023 Alice Jean FOX · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 6 Delays in obtaining blood results needed to confirm suspected infection View source Lack of protocols ensuring safe and appropriate multi-party discharge arrangements View source Delays in clinical review and referral for suspected infection after rehabilitation-hospital arrival View source Lack of close checks and observations for patients in the hospital discharge lounge View source Failure to complete core admission assessments after late-night arrival at the rehabilitation hospital View source Failure to respond appropriately to suspected infection when NEWS scores are low View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Alice Jean FOX · 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
Alice Jean FOX, known as Jean, died in hospital on 1 July 2021 from severe infection resulting from bacterial infection of the surgical site following partial hip replacement after a fall. Concerns included her lengthy wait in the discharge lounge and late arrival at rehabilitation, which meant usual admission assessments were not completed, and delays in reviewing blood results and referring her back to hospital despite signs of infection.
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 Derbyshire Community Health Services NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining blood results needed to confirm suspected infection
Wider context from the report “2. Jean had signs of infection to the surgical site on arrival at the rehabilitation hospital and should have had more robust clinical review but confirmation of infection and referral back to the general hospital did not occur until her blood results were reviewed 3 days later. There had been opportunity to expedite the blood results . On the evidence at inquest there is reason to think that the rehabilitation staff were falsely reassured by a low NEWS score whereas there was suspected infection that could have been confirmed earlier.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Derbyshire Community Health Services NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of protocols ensuring safe and appropriate multi-party discharge arrangements
Wider context from the report “1. Jean had spent a lengthy period in the general hospital discharge lounge, during which time which she would not have had close checks and observations as compared to ward-based care. She did not arrive at the rehabilitation hospital until late at night and so did not have the usual core admission assessments. Such situations appear to me to have the potential to place patients such as Jean at significant risk. Given that there would usually be three parties involved in the transfer (the discharging hospital, the transporting ambulance service, and the discharge destination) there is opportunity for consideration of protocols to ensure such discharge arrangements are safe and appropriate .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Derbyshire Community Health Services NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in clinical review and referral for suspected infection after rehabilitation-hospital arrival
Wider context from the report “2. Jean had signs of infection to the surgical site on arrival at the rehabilitation hospital and should have had more robust clinical review but confirmation of infection and referral back to the general hospital did not occur until her blood results were reviewed 3 days later . There had been opportunity to expedite the blood results. On the evidence at inquest there is reason to think that the rehabilitation staff were falsely reassured by a low NEWS score whereas there was suspected infection that could have been confirmed earlier.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Derbyshire Community Health Services NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of close checks and observations for patients in the hospital discharge lounge
Wider context from the report “1. Jean had spent a lengthy period in the general hospital discharge lounge, during which time which she would not have had close checks and observations as compared to ward-based care . She did not arrive at the rehabilitation hospital until late at night and so did not have the usual core admission assessments. Such situations appear to me to have the potential to place patients such as Jean at significant risk. Given that there would usually be three parties involved in the transfer (the discharging hospital, the transporting ambulance service, and the discharge destination) there is opportunity for consideration of protocols to ensure such discharge arrangements are safe and appropriate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Derbyshire Community Health Services NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete core admission assessments after late-night arrival at the rehabilitation hospital
Wider context from the report “1. Jean had spent a lengthy period in the general hospital discharge lounge, during which time which she would not have had close checks and observations as compared to ward-based care. She did not arrive at the rehabilitation hospital until late at night and so did not have the usual core admission assessments . Such situations appear to me to have the potential to place patients such as Jean at significant risk. Given that there would usually be three parties involved in the transfer (the discharging hospital, the transporting ambulance service, and the discharge destination) there is opportunity for consideration of protocols to ensure such discharge arrangements are safe and appropriate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Derbyshire Community Health Services NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to respond appropriately to suspected infection when NEWS scores are low
Wider context from the report “2. Jean had signs of infection to the surgical site on arrival at the rehabilitation hospital and should have had more robust clinical review but confirmation of infection and referral back to the general hospital did not occur until her blood results were reviewed 3 days later. There had been opportunity to expedite the blood results. On the evidence at inquest there is reason to think that the rehabilitation staff were falsely reassured by a low NEWS score whereas there was suspected infection that could have been confirmed earlier.
” Open source report
4 Apr 2017 Kimberley Holden · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Unsafe prescribing of controlled drugs View source Poorly coordinated management and prescribing in neurological patients View source Limited understanding of the duty to report serious prescribing incidents 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
Kimberley Holden · 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
Kimberley Holden, who had a chronic neurological condition and chronic pain, died from Oxycodone toxicity on 26 November 2014 after a dose significantly higher than intended was prescribed. The concerns included unsafe prescribing of controlled drugs and poorly coordinated management and prescribing 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 Derbyshire Community Health Services NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unsafe prescribing of controlled drugs
Wider context from the report “1. The continuing risk of unsafe prescribing of controlled drugs by the Ivy Grove Surgery, and the limited understanding of the duty to report serious prescribing incidents.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Derbyshire Community Health Services NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poorly coordinated management and prescribing in neurological patients
Wider context from the report “2. The continuing risk of poorly coordinated management and prescribing in neurological patients under the care of both DCHS and the Derby Hospital
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Derbyshire Community Health Services NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited understanding of the duty to report serious prescribing incidents
Wider context from the report “1. The continuing risk of unsafe prescribing of controlled drugs by the Ivy Grove Surgery, and the limited understanding of the duty to report serious prescribing incidents .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations