25 Feb 2026 Emma Irene TURNER · Prevention of Future Deaths report Derby and Derbyshire
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Concerns raised 3 Insufficient support and assistance for carers in understanding a person's best interests View source Lack of connectivity and information sharing between services View source Safeguarding referral forms failing to capture key GP-relevant information View source
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Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Emma Irene TURNER · 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
Emma Irene Turner died at home on 29 January 2023 after her airway became obstructed by vomit following her eating some cake. The report identified concerns about inadequate and untimely multi-agency processes, safeguarding referrals, face-to-face assessments and welfare checks, as well as poor information sharing between services. It also identified a risk that the safeguarding referral form used by GPs could omit key information and delay responses.
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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 Derbyshire County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient support and assistance for carers in understanding a person's best interests
Wider context from the report “It is clear that her family cared and supported her but at the inquest the evidence exposed important issues with information sharing between services. Her mother, her carer should have been given more support and assisted in understanding what was in Emma’s best interests.
The evidence at the inquest revealed a lack of connectivity between information systems used by different agencies; that impacted on their ability to review how other professionals would intervene in Emma's care. There had been a history of non-attendance and reluctance on the part of family members to engage with services. As a result, safeguarding referrals were made in 2018 by the Day Centre she had attended and in 2019 by a social worker after her discussions with the advanced nurse practitioner at the GP surgery.
Although the evidence from the GP surgery, Derby City Council and their safeguarding team confirm that since Emma's death a number of relevant changes were being made to look after patients with learning difficulties particularly where they have not been brought to multiple appointments, in so far as the contents of the present safeguarding referral form which needs to be completed by a GP for vulnerable and learning difficulties adults, that present form is not tailored to the type of concerns that a GP would raise. The safeguarding template questions ask a variety of questions that are not relevant to a GP but to other agencies e.g. care homes, the police and community mental health teams. As a result there is a risk of there being a lack of key information provided to the safeguarding teams. Thus the safeguarding team may be delayed in responding in a timely way.
” Open source report × Source evidence
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of connectivity and information sharing between services
Wider context from the report “It is clear that her family cared and supported her but at the inquest the evidence exposed important issues with information sharing between services . Her mother, her carer should have been given more support and assisted in understanding what was in Emma’s best interests.
The evidence at the inquest revealed a lack of connectivity between information systems used by different agencies ; that impacted on their ability to review how other professionals would intervene in Emma's care . There had been a history of non-attendance and reluctance on the part of family members to engage with services. As a result, safeguarding referrals were made in 2018 by the Day Centre she had attended and in 2019 by a social worker after her discussions with the advanced nurse practitioner at the GP surgery.
Although the evidence from the GP surgery, Derby City Council and their safeguarding team confirm that since Emma's death a number of relevant changes were being made to look after patients with learning difficulties particularly where they have not been brought to multiple appointments, in so far as the contents of the present safeguarding referral form which needs to be completed by a GP for vulnerable and learning difficulties adults, that present form is not tailored to the type of concerns that a GP would raise. The safeguarding template questions ask a variety of questions that are not relevant to a GP but to other agencies e.g. care homes, the police and community mental health teams. As a result there is a risk of there being a lack of key information provided to the safeguarding teams. Thus the safeguarding team may be delayed in responding in a timely way.
” Open source report × Source evidence
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Safeguarding referral forms failing to capture key GP-relevant information
Wider context from the report “It is clear that her family cared and supported her but at the inquest the evidence exposed important issues with information sharing between services. Her mother, her carer should have been given more support and assisted in understanding what was in Emma’s best interests.
The evidence at the inquest revealed a lack of connectivity between information systems used by different agencies; that impacted on their ability to review how other professionals would intervene in Emma's care. There had been a history of non-attendance and reluctance on the part of family members to engage with services. As a result, safeguarding referrals were made in 2018 by the Day Centre she had attended and in 2019 by a social worker after her discussions with the advanced nurse practitioner at the GP surgery.
Although the evidence from the GP surgery, Derby City Council and their safeguarding team confirm that since Emma's death a number of relevant changes were being made to look after patients with learning difficulties particularly where they have not been brought to multiple appointments, in so far as the contents of the present safeguarding referral form which needs to be completed by a GP for vulnerable and learning difficulties adults, that present form is not tailored to the type of concerns that a GP would raise. The safeguarding template questions ask a variety of questions that are not relevant to a GP but to other agencies e.g. care homes, the police and community mental health teams. As a result there is a risk of there being a lack of key information provided to the safeguarding teams . Thus the safeguarding team may be delayed in responding in a timely way .
” Open source report
8 Sep 2025 Maureen Gilbert · Prevention of Future Deaths report Derby and Derbyshire
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Concerns raised 1 Lack of flood defences at Tapton Terrace View source
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Maureen Gilbert · Prevention of Future Deaths report
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Report summary
Maureen Gilbert, who was 83 years old, drowned in her home on 21 October 2023 after flood waters entered her property during Storm Babet. The report raises concern that the absence of flood defences at Tapton Terrace leaves residents, particularly those who may be elderly, vulnerable or immobile, at risk of life.
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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 Derbyshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of flood defences at Tapton Terrace
Wider context from the report “Following the flood damage to Tapton Terrace in 2007, the Environment Agency’s pre-feasibility study identified a number of technically feasible options that would reduce the flood risk at Tapton Terrace. None of these measures were implemented principally due to cost reasons. When Storm Babet hit in October 2023, Tapton Terrace remained in the same position that it was in back in 2007. Due to the ongoing lack of flood defences, Tapton Terrace remains vulnerable to flooding. I am concerned that this gives rise to a risk to life, particularly in respect of residents who may be elderly, vulnerable or immobile.
” 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 Explore the feasibility of constructing a Spital Brook Flood Alleviation Scheme providing upstream attenuation during heavy rainfall.
Verbatim wording from the response “DCC is also exploring the feasibility of constructing a Flood Alleviation Scheme on the Spital Brook, which is an ordinary watercourse (rather than a main river) and would therefore fall under the remit of DCC as the Lead Local Flood Authority to consider, rather than the EA. The scheme would provide upstream attenuation in times of heavy rainfall, thereby potentially reducing the flood risk further downstream, at the point it connects into the River Rother. To date, two grant funding bids have been submitted which would fund the feasibility study of such a scheme. The outcome of these two bids is expected to be around February/March 2026. It’s worth noting that a scheme of this magnitude would take approximately 5 to 10 years to deliver and is subject to appropriate funding being made available.” Source location Response from Derbyshire County Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore the feasibility of removing the access bridge, using Environment Agency modelling and evidence to assess whether removal would reduce flood risk.
Verbatim wording from the response “DCC is currently exploring the feasibility of removing an access bridge, which is located over the River Rother, just to the south of Tapton Terrace. The access bridge is public highway and is the responsibility of the authority to manage and maintain. Removal of the access bridge may provide a benefit in terms of reducing the flood risk to Tapton Terrace and surrounding flood areas. There would be a requirement to utilise the EA’s modelling and expertise, in order to evidence that removal of the bridge will actually reduce the flood risk. To explain what modelling is, the EA have river models which simulate the flows and depths over a range of different storm events, which can be used to aid feasibility and design of a flood risk scheme.” Source location Response from Derbyshire County Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Submit grant funding bids to support a feasibility study for a Spital Brook Flood Alleviation Scheme.
Verbatim wording from the response “DCC is also exploring the feasibility of constructing a Flood Alleviation Scheme on the Spital Brook, which is an ordinary watercourse (rather than a main river) and would therefore fall under the remit of DCC as the Lead Local Flood Authority to consider, rather than the EA. The scheme would provide upstream attenuation in times of heavy rainfall, thereby potentially reducing the flood risk further downstream, at the point it connects into the River Rother. To date, two grant funding bids have been submitted which would fund the feasibility study of such a scheme. The outcome of these two bids is expected to be around February/March 2026. It’s worth noting that a scheme of this magnitude would take approximately 5 to 10 years to deliver and is subject to appropriate funding being made available.” Source location Response from Derbyshire County Council
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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 Bridge removal cannot yet be considered without Environment Agency modelling and evidence demonstrating that it would reduce flood risk.
Verbatim wording from the response “DCC is currently exploring the feasibility of removing an access bridge, which is located over the River Rother, just to the south of Tapton Terrace. The access bridge is public highway and is the responsibility of the authority to manage and maintain. Removal of the access bridge may provide a benefit in terms of reducing the flood risk to Tapton Terrace and surrounding flood areas. There would be a requirement to utilise the EA’s modelling and expertise, in order to evidence that removal of the bridge will actually reduce the flood risk. To explain what modelling is, the EA have river models which simulate the flows and depths over a range of different storm events, which can be used to aid feasibility and design of a flood risk scheme.” Source location Response from Derbyshire County Council
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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 Flood mitigation schemes depend on government grant funding, and delivery cannot proceed without appropriate funding being available.
Verbatim wording from the response “DCC is also exploring the feasibility of constructing a Flood Alleviation Scheme on the Spital Brook, which is an ordinary watercourse (rather than a main river) and would therefore fall under the remit of DCC as the Lead Local Flood Authority to consider, rather than the EA. The scheme would provide upstream attenuation in times of heavy rainfall, thereby potentially reducing the flood risk further downstream, at the point it connects into the River Rother. To date, two grant funding bids have been submitted which would fund the feasibility study of such a scheme. The outcome of these two bids is expected to be around February/March 2026. It’s worth noting that a scheme of this magnitude would take approximately 5 to 10 years to deliver and is subject to appropriate funding being made available.” Source location Response from Derbyshire County Council
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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 Responsibility for managing flood risk from the River Rother main river rests primarily with the Environment Agency.
Verbatim wording from the response “Derbyshire County Council (“DCC”) in its capacity as Lead Local Flood Authority (Floods and Water Management Act 2010) has the lead responsibility for managing local flood risk, from surface water, groundwater and ordinary watercourses. The Environment Agency is responsible for taking a strategic overview of the management of all sources of flooding and coastal erosion.” Source location Response from Derbyshire County Council
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7 May 2024 Matthew SCOTT · Prevention of Future Deaths report Derby and Derbyshire
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Concerns raised 2 Failure to survey and act on reported road defects View source Defective and subsided road surface capable of accumulating ice View source
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AI-generated summary
Matthew SCOTT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew James Scott died on 11 March 2023 after losing control of his vehicle on Station Road, Melbourne, when it hit a lengthy defective and subsided section of road filled with ice. The report identifies concerns that the road defect had not been surveyed or addressed by the date of the inquest, despite concerns raised by police and the highways authority.
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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 Derbyshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to survey and act on reported road defects
Wider context from the report “At 6 weeks post Mr Scott's death - on the 28th of April 2023 - a discussion took place between collision investigator officers, a traffic management officer (all of Derbyshire police) with the Project Engineer of the Highways Authority of Derbyshire County Council. The officers raised their concerns that at the place where Mr Scott lost control of his vehicle (Station Road, Melbourne Derbyshire) there was a lengthy, defective and subsided stretch of road. Further that at the time of Mr Scott's death the subsided section of road was some 4 metres in width, 37 metres in length and 5 cms in depth. Further, that it was deep enough to have had standing water in it which at the time of Mr Scott's death had turned to ice.
Ice in the said defect would likely cause a vehicle to lose grip on the road surface. At that section of road, the road starts to bend to the right such that losing control on the ice could cause a vehicle to veer to the offside of the road, either into the path of an oncoming vehicle, into the opposite field or as in Mr Scott’s case, a tree.
The Project Engineer of the Highways Authority discussed his concerns and the concerns that had been raised by the police, with the highway maintenance department in early May 2023. As at the date of the inquest into Mr Scott' death (22 April 2024) this stretch of road had not been surveyed , no consideration had been given to the concerns of the police and no decisions taken to repair the defect so as to prevent any further accidents.
” Open source report × Source evidence
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Defective and subsided road surface capable of accumulating ice
Wider context from the report “At 6 weeks post Mr Scott's death - on the 28th of April 2023 - a discussion took place between collision investigator officers, a traffic management officer (all of Derbyshire police) with the Project Engineer of the Highways Authority of Derbyshire County Council. The officers raised their concerns that at the place where Mr Scott lost control of his vehicle (Station Road, Melbourne Derbyshire) there was a lengthy, defective and subsided stretch of road . Further that at the time of Mr Scott's death the subsided section of road was some 4 metres in width, 37 metres in length and 5 cms in depth . Further, that it was deep enough to have had standing water in it which at the time of Mr Scott's death had turned to ice .
Ice in the said defect would likely cause a vehicle to lose grip on the road surface . At that section of road, the road starts to bend to the right such that losing control on the ice could cause a vehicle to veer to the offside of the road, either into the path of an oncoming vehicle, into the opposite field or as in Mr Scott’s case, a tree.
The Project Engineer of the Highways Authority discussed his concerns and the concerns that had been raised by the police, with the highway maintenance department in early May 2023. As at the date of the inquest into Mr Scott' death (22 April 2024) this stretch of road had not been surveyed, no consideration had been given to the concerns of the police and no decisions taken to repair the defect so as to prevent any further accidents.
” 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 Undertake full-width resurfacing from Melbourne View Hotel approximately 200 metres eastward to level road-surface deviations.
Verbatim wording from the response “Nonetheless Derbyshire County Council take road safety very seriously and the area from Melbourne View Hotel to a point approximately 200 metres in an easterly direction has been put in for full width road surfacing work to be undertaken. This will be completed by 31 October 2024 and will level some of the deviations in the road surface caused by various pot hole repairs.” Source location Response from Derbyshire County Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conducted a laser survey of Station Road to assess whether an actionable safety defect existed.
Verbatim wording from the response “Due to the inconsistency between the site report carried out by ████████ and the concerns raised by the Coroner Derbyshire County Council have undertaken a laser survey dated 26/04/2024. The results of the survey also clearly shows there was not an actionable safety defect that measured 4m wide by 37 meters in length, as that was the ice formation.” Source location Response from Derbyshire County Council
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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 Quarterly inspections by competent inspectors were sufficient to identify and repair significant road defects.
Verbatim wording from the response “As referenced above the road in question, Station Road, Melbourne is subject to quarterly inspections. We have noted the following from records;
13 January 2023 – 2 customer reports of pot hole received on the same day – area put in for ad hoc inspection
17 January 2023 - ad hoc inspection – a number of separate pot holes put in for repair ref. 50186345 works completed 1 March 2023
17 February 2023 routine inspection – defect noted – 28 day repair requested ref. 50189695 - completed 20 February 2023
9 May 2023 – routine inspection – jobs raised outside Melbourne view repair requested ref 50197481– completed 30 May 2023
17 August 2023 – routine inspection – potholes repairs requested ref. 50204692 and 50204693 completed 04 September 2023.
22 November 2023 – routine inspection – potholes repairs requested ref. 50210507 completed on 21 December 2023.” Source location Response from Derbyshire County Council
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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 reported 37-metre-wide road defect was ice formation, not an actionable safety defect; pooled water was limited and typical.
Verbatim wording from the response “The site report states as follows “Large patch of ice on the road surface measuring 4 metres in diameter and 37 meters in length. Commencing in the centre of the carriageway, 4 meters prior to the entrance of the Melbourne Hotel, and terminating in the south-east bound lane. The area predominantly covered the south-east bound lane. It must be noted that this had reduced in size during my attendance due to weather conditions”. This does not say that there was a defect in the road but ice formation. There were some minor differences in level within the carriageway which allowed water to stand, such minor differences in level would be typical of an evolved road network in similar settings such as this and other areas of road across the county.” Source location Response from Derbyshire County Council
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30 May 2022 Mark SUMNALL · Prevention of Future Deaths report Derby and Derbyshire
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Concerns raised 3 Failure to check Red Bag contents for relevant information View source Failure to implement and routinely use the Red Bag scheme across care and hospital admissions View source Failure to make systematic enquiries for care plans and other relevant documentation between agencies View source
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Mark SUMNALL · 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
Mark Sumnall died in hospital on the morning of 21 December 2020 after choking and aspirating on a sandwich given by hospital staff. He had a recognised choking risk, but hospital staff were not aware of it despite his care plan being sent with him in a Red Bag. The report raised concerns about failures to identify and use the Red Bag and to transfer relevant care and risk information between the care home, ambulance service and hospital.
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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 Derbyshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to check Red Bag contents for relevant information
Wider context from the report “The Derbyshire wide Red Bag scheme is an initiative designed to ensure that when care home residents are admitted to hospital, key health and social care information travels with them by way of documentation such as care plans (as well as medication and essential personal items). I understand that the County Council and the CCG are the primary agencies responsible for the scheme. On the evidence considered at Mr Sumnall's inquest: -
1. The scheme does not appear to be widely used in Derbyshire, although the scheme was in response to NICE guidance for improving patient care and safety when transferring between health and care settings (NG27: Transition between inpatient hospital setting and community or care homes). The inquest heard that Mr Sumnall’s care home only had one bag for use on the premises, and that ambulance and hospital staff did not routinely deal with admissions where care home patients were sent with Red Bags.
2. The Red Bag travelled with Mr Sumnall and was found with his clothes when he died. Despite being with him there is no evidence that anyone looked in the bag to check for relevant information . This being the case it appears to me that there is lack of awareness of how the bag should be used , but also, as no enquiries were separately made for care plan and other relevant documentation, that the thrust of the NICE guidance for improving patient care and safety is not being addressed systematically between agencies.
” Open source report × Source evidence
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to implement and routinely use the Red Bag scheme across care and hospital admissions
Wider context from the report “The Derbyshire wide Red Bag scheme is an initiative designed to ensure that when care home residents are admitted to hospital, key health and social care information travels with them by way of documentation such as care plans (as well as medication and essential personal items). I understand that the County Council and the CCG are the primary agencies responsible for the scheme. On the evidence considered at Mr Sumnall's inquest: -
1. The scheme does not appear to be widely used in Derbyshire , although the scheme was in response to NICE guidance for improving patient care and safety when transferring between health and care settings (NG27: Transition between inpatient hospital setting and community or care homes). The inquest heard that Mr Sumnall’s care home only had one bag for use on the premises , and that ambulance and hospital staff did not routinely deal with admissions where care home patients were sent with Red Bags .
2. The Red Bag travelled with Mr Sumnall and was found with his clothes when he died. Despite being with him there is no evidence that anyone looked in the bag to check for relevant information. This being the case it appears to me that there is lack of awareness of how the bag should be used, but also, as no enquiries were separately made for care plan and other relevant documentation, that the thrust of the NICE guidance for improving patient care and safety is not being addressed systematically between agencies.
” Open source report × Source evidence
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to make systematic enquiries for care plans and other relevant documentation between agencies
Wider context from the report “The Derbyshire wide Red Bag scheme is an initiative designed to ensure that when care home residents are admitted to hospital, key health and social care information travels with them by way of documentation such as care plans (as well as medication and essential personal items). I understand that the County Council and the CCG are the primary agencies responsible for the scheme. On the evidence considered at Mr Sumnall's inquest: -
1. The scheme does not appear to be widely used in Derbyshire, although the scheme was in response to NICE guidance for improving patient care and safety when transferring between health and care settings (NG27: Transition between inpatient hospital setting and community or care homes). The inquest heard that Mr Sumnall’s care home only had one bag for use on the premises, and that ambulance and hospital staff did not routinely deal with admissions where care home patients were sent with Red Bags.
2. The Red Bag travelled with Mr Sumnall and was found with his clothes when he died. Despite being with him there is no evidence that anyone looked in the bag to check for relevant information. This being the case it appears to me that there is lack of awareness of how the bag should be used, but also, as no enquiries were separately made for care plan and other relevant documentation , that the thrust of the NICE guidance for improving patient care and safety is not being addressed systematically between agencies .
” 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 Review the red-bag pathway’s sustainability, associated risks and opportunities for a sustainable countywide approach.
Verbatim wording from the response “4. Review the sustainability of the red bag pathway including consideration of the risks associated with it and opportunities to implement a sustainable approach across the whole of the County footprint. Implement an interim transfer document for use when transferring individuals from care homes to hospital and hospital to care homes pending the digital solution being implemented. The timescale for full roll-out of this across Derbyshire is by the end of September 2022.” Source location Response from Derbyshire County Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Agree acute-trust actions for robust handover communications and investigation of red-bag contents when care homes use them.
Verbatim wording from the response “3. For the CCG lead to meet with the Deputy Directors of Nursing from both Acute Trusts to agree the internal actions each will take to ensure effective and robust handover communications when receiving patients into the hospital in both the emergency department and on assessment and treatment wards. This will include investigation of the contents of red bags when they are used by care homes. The timescale for completion of this was by the end of July 2022 and this has been completed.” Source location Response from Derbyshire County Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise, approve and distribute urgent red-bag communications to ambulance and hospital trusts, including contents and checking requirements.
Verbatim wording from the response “2. Revise, approve and distribute urgent communications to ambulance trust and hospital trusts previous guidance regarding red bags. Include that a number of red bags continue to be used across Derbyshire, that we are reviewing long term sustainability and ensure all staff members are aware of the contents of the red bag and the importance of them checking the contents as they include crucial information regarding individuals’ needs and any associated risks. The timescale for completion was by the end of July 2022 – and this has been completed.” Source location Response from Derbyshire County Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop, approve and disseminate urgent communications asking care homes to use red bags and revising transfer guidance where bags are unavailable.
Verbatim wording from the response “1. Develop, approve and disseminate urgent communications to care homes asking them to utilise red bags where they have them. Review previous guidance on the scheme and revise and develop guidance on formal communication and handover requirements when transferring a resident to hospital where they do not have a red bag. The timescale for completion of this was by the end of July 2022 and it has been completed.” Source location Response from Derbyshire County Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the urgent-transfer information standard and liaise with digital-transformation leads to expedite an integrated care system digital-standards initiative.
Verbatim wording from the response “5. Review the Urgent transfer from care home to hospital information standard and link with the local NHS and Local Authority digital transformation leads to expedite an Integrated Care System-wide initiative to implement the new digital standards. This would enable care homes to digitise and transfer individuals’ records electronically to hospital containing all relevant information. The timeframe for the discussion with local NHS and Local Authority digital transformation leads is the end of August 2022. By March 2024, 80% of adult social care providers registered with the Care Quality Commission will have digital social care records, with progress well underway for the remaining 20% by that date.” Source location Response from Derbyshire County Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement ongoing cross-provider quality monitoring and assurance to assess compliance and impact, take corrective action, and report performance to the steering group.
Verbatim wording from the response “6. For effective quality monitoring and assurance mechanisms to be implemented and delivered across care home provision, ambulance and hospital trusts to monitor compliance and impact of the above actions and taking corrective action where indicated. For performance to be reported to the Integrated Care Homes Steering Group for monitoring and multi-agency action. The timescale for implementation of this is from August 2022 on an ongoing basis.” Source location Response from Derbyshire County Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an interim transfer document for transfers between care homes and hospitals pending the digital solution.
Verbatim wording from the response “4. Review the sustainability of the red bag pathway including consideration of the risks associated with it and opportunities to implement a sustainable approach across the whole of the County footprint. Implement an interim transfer document for use when transferring individuals from care homes to hospital and hospital to care homes pending the digital solution being implemented. The timescale for full roll-out of this across Derbyshire is by the end of September 2022.” Source location Response from Derbyshire County Council
Open published response
23 Jun 2021 Heather Frances Page · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Railway track with multiple easy access points near a popular beauty spot increasing suicide risk View source Pedestrian crossings requiring people to walk on railway tracks View source Dependence on local authority support for closing or rationalising crossings View source Failure to reduce or rationalise the number of crossings View source High fatality rate along the section of track View source See 2 more concerns
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AI-generated summary
Heather Frances Page · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 7 October 2020, Heather Frances Page stepped in front of a train and died in the resulting collision. The report identified concerns about pedestrian crossings requiring people to walk on the tracks, a high number of fatalities, ease of access to the track, and difficulties reducing or rationalising crossings because of local authority opposition.
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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 Derbyshire County Council; that does not assign responsibility.
PFD Monitor interpretation Railway track with multiple easy access points near a popular beauty spot increasing suicide risk
Wider context from the report “Evidence was heard regarding the section of track adjacent to the Attenborough Nature Reserve. I noted the following issues of concern in relation to this section of track:-
(1) There are a number of pedestrian crossings along this short stretch of track which involve pedestrians having to walk on the tracks to cross to the other side.
(2) There has been a high number of fatalities along this short section of track (seven in as many years).
(3) The nature of that section of track is such that it increases the risks of completed suicide due to the ease of access at multiple points and its proximity to a very popular beauty spot .
(4) Efforts by Network Rail to reduce / rationalise the number of crossings along that stretch have failed due, in part, to opposition from the relevant local authorities.
(5) Support or opposition from local authorities and councils will respectively increase or reduce the prospects of the risks inherent in that stretch of track being reduced. In the absence of support from local authorities and councils, Network Rail will be less likely to make an application to close or rationalise crossings along this section of track, given the known opposition from some persons living near, or using, the crossings. If an application is made, it will be less likely to be granted in the absence of support from the relevant local authorities and councils.
” Open source report × Source evidence
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Pedestrian crossings requiring people to walk on railway tracks
Wider context from the report “Evidence was heard regarding the section of track adjacent to the Attenborough Nature Reserve. I noted the following issues of concern in relation to this section of track:-
(1) There are a number of pedestrian crossings along this short stretch of track which involve pedestrians having to walk on the tracks to cross to the other side.
(2) There has been a high number of fatalities along this short section of track (seven in as many years).
(3) The nature of that section of track is such that it increases the risks of completed suicide due to the ease of access at multiple points and its proximity to a very popular beauty spot.
(4) Efforts by Network Rail to reduce / rationalise the number of crossings along that stretch have failed due, in part, to opposition from the relevant local authorities.
(5) Support or opposition from local authorities and councils will respectively increase or reduce the prospects of the risks inherent in that stretch of track being reduced. In the absence of support from local authorities and councils, Network Rail will be less likely to make an application to close or rationalise crossings along this section of track, given the known opposition from some persons living near, or using, the crossings. If an application is made, it will be less likely to be granted in the absence of support from the relevant local authorities and councils.
” Open source report × Source evidence
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Dependence on local authority support for closing or rationalising crossings
Wider context from the report “Evidence was heard regarding the section of track adjacent to the Attenborough Nature Reserve. I noted the following issues of concern in relation to this section of track:-
(1) There are a number of pedestrian crossings along this short stretch of track which involve pedestrians having to walk on the tracks to cross to the other side.
(2) There has been a high number of fatalities along this short section of track (seven in as many years).
(3) The nature of that section of track is such that it increases the risks of completed suicide due to the ease of access at multiple points and its proximity to a very popular beauty spot.
(4) Efforts by Network Rail to reduce / rationalise the number of crossings along that stretch have failed due, in part, to opposition from the relevant local authorities.
(5) Support or opposition from local authorities and councils will respectively increase or reduce the prospects of the risks inherent in that stretch of track being reduced. In the absence of support from local authorities and councils, Network Rail will be less likely to make an application to close or rationalise crossings along this section of track , given the known opposition from some persons living near, or using, the crossings. If an application is made, it will be less likely to be granted in the absence of support from the relevant local authorities and councils.
” Open source report × Source evidence
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to reduce or rationalise the number of crossings
Wider context from the report “Evidence was heard regarding the section of track adjacent to the Attenborough Nature Reserve. I noted the following issues of concern in relation to this section of track:-
(1) There are a number of pedestrian crossings along this short stretch of track which involve pedestrians having to walk on the tracks to cross to the other side.
(2) There has been a high number of fatalities along this short section of track (seven in as many years).
(3) The nature of that section of track is such that it increases the risks of completed suicide due to the ease of access at multiple points and its proximity to a very popular beauty spot.
(4) Efforts by Network Rail to reduce / rationalise the number of crossings along that stretch have failed due, in part, to opposition from the relevant local authorities.
(5) Support or opposition from local authorities and councils will respectively increase or reduce the prospects of the risks inherent in that stretch of track being reduced. In the absence of support from local authorities and councils, Network Rail will be less likely to make an application to close or rationalise crossings along this section of track, given the known opposition from some persons living near, or using, the crossings. If an application is made, it will be less likely to be granted in the absence of support from the relevant local authorities and councils.
” Open source report × Source evidence
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 County Council; that does not assign responsibility.
PFD Monitor interpretation High fatality rate along the section of track
Wider context from the report “Evidence was heard regarding the section of track adjacent to the Attenborough Nature Reserve. I noted the following issues of concern in relation to this section of track:-
(1) There are a number of pedestrian crossings along this short stretch of track which involve pedestrians having to walk on the tracks to cross to the other side.
(2) There has been a high number of fatalities along this short section of track (seven in as many years).
(3) The nature of that section of track is such that it increases the risks of completed suicide due to the ease of access at multiple points and its proximity to a very popular beauty spot.
(4) Efforts by Network Rail to reduce / rationalise the number of crossings along that stretch have failed due, in part, to opposition from the relevant local authorities.
(5) Support or opposition from local authorities and councils will respectively increase or reduce the prospects of the risks inherent in that stretch of track being reduced. In the absence of support from local authorities and councils, Network Rail will be less likely to make an application to close or rationalise crossings along this section of track, given the known opposition from some persons living near, or using, the crossings. If an application is made, it will be less likely to be granted in the absence of support from the relevant local authorities and councils.
” 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 other agencies to improve safety across Derbyshire and help prevent fatalities within the Council’s legal powers.
Verbatim wording from the response “We are aware of the report undertaken by British Transport Police in November 2020 and as a local authority we will do whatever is within our legal power to assist in the prevention of fatalities however it will take a coordinated approach from the various local councils, Network Rail and the Highways Authority in order to achieve this. Derbyshire County Council as the relevant Highway Authority for Derbyshire will always work with other agencies to improve safety across the County.” Source location 2021-0213-Response-from-Derbyshire-County-Council_Published
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 Network Rail would have to apply under section 119A of the Highways Act 1980 to divert the public footpath’s current alignment.
Verbatim wording from the response “The correspondence indicated that the planners within Network Rail were planning on making contact with the local planning authority, which would be Erewash Borough Council in this regard, in relation to the proposed design that had been prepared. It was identified that you would have to make an application under Section 119a of the Highways Act 1980 to divert the public footpaths current alignment. To the best of our knowledge Derbyshire County Council received no further correspondence from Network Rail in relation to this matter.” Source location 2021-0213-Response-from-Derbyshire-County-Council_Published
Open published response
3 Jul 2019 Mr Thomas Andrew Reid · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 3 Failure to implement a response to the known junction warning risk View source Insufficiently visible advance warning of the road junction View source Road junction posing a recurring collision hazard 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
Mr Thomas Andrew Reid · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Thomas Andrew Reid, aged 27, died at the roadside from injuries sustained in a road traffic collision on 21 September 2018 while riding his motorbike along the A515 near Sudbury in Ashbourne. The collision occurred as he overtook queued traffic and collided with a tractor turning right into the B5033. Concerns included the possibility that the only advance warning sign for the junction could be obscured by large vehicles, worn junction markings, previous incidents at the location, and uncertainty about action to address the known risk.
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to implement a response to the known junction warning risk
Wider context from the report “3. Evidence also emerged at the inquest that Derby County Council was aware of the issue and were looking at more signage, larger signs and additional pre-warning signs. This was discussed last October at a Derbyshire County Council meeting. It was not known what, if anything, Derbyshire County Council would do about this known risk .
” Open source report × Source evidence
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficiently visible advance warning of the road junction
Wider context from the report “2. The route marker board 155 meters from the junction, is the only advanced warning of the junction ahead . The location and scale of the sign mean that it could be obscured by passing large vehicles, such as LGV’s, especially if they are slow moving . This happens often given the presence of the junction .
” Open source report × Source evidence
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Road junction posing a recurring collision hazard
Wider context from the report “1. Evidence emerged during the inquest that there were at least two previous incidents along that part of the road . Once causing fatal injuries and one causing critical injuries. Additionally numerous other minor incidents .
” Open source report
12 May 2018 CHARLES EVAN GRAINGER · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 2 Failure of multi-agencies to share patients' past medical history, including previous falls history View source Failure to undertake basic and proper investigations of falls risk assessments 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
CHARLES EVAN GRAINGER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Charles Evan Grainger was admitted to Milford House Residential Unit after a fall and later sustained injuries in a witnessed fall there on 24 November 2013. The inquest concluded that his death was accidental, with the medical cause recorded as bronchopneumonia and central cord syndrome. Concerns included failures to share his history of falls between relevant agencies and inadequate investigation of the circumstances surrounding his fall.
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of multi-agencies to share patients' past medical history, including previous falls history
Wider context from the report “(1) Relevant information regarding Mr Grainger's falls history could not be shared by his Social Worker with other relevant Multi Agencies such as Milford House or the Health Team at the time his Pre Admission Assessment was undertaken as the process/system did not allow it . Milford House, the Local Authority and the Health Team should have all worked together, more cohesively to ensure they were working in Mr Grainger's best interests. Failure of Multi Agencies to work more cohesively in the future by sharing a patients past medical history, including previous falls history could result in vital information being missed and future deaths occurring.
” Open source report × Source evidence
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake basic and proper investigations of falls risk assessments
Wider context from the report “(2) ████████ did not consider it important or necessary to request, review or retain copies of Mr Grainger's falls risk assessment as part of her basic investigation enquiries . Failure to undertake a basic and proper investigation could result in future deaths occurring.
” Open source report
16 Oct 2015 Louise Sharon Henry · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 5 Lack of GP awareness and use of EMIS Special Patient Note and Right Care Plan facilities for mental health risk information View source Failure to ensure shared understanding of care co-ordinator roles and Care Programme Approach responsibilities View source Failure of discharge letters to identify mental health relapse risks and indicators View source Failure to distinguish Recovery Team services operated by different agencies View source Failure to follow required patient discharge processes and procedures View source See 2 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
Louise Sharon Henry · 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
Louise Sharon Henry was found deceased at home on 1 April 2013 after consuming a substantial amount of amphetamine and ibuprofen while experiencing a deterioration in her mental state, including psychotic symptoms and hallucinations. The report identified concerns about her discharge from mental health services, including failures to communicate relapse triggers and a clear contingency plan, lack of reassessment after reports of deterioration, and ambiguity between agencies about care-coordination roles and procedures.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Derbyshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of GP awareness and use of EMIS Special Patient Note and Right Care Plan facilities for mental health risk information
Wider context from the report “4. That GPs do not appreciate the use that can be made of the Special Patient Note facility and Right Care plan facility on the EMIS system operated by GPs. I heard evidence that key information relating to patients and in particular mental health patients can be updated on to the Special Patient Note facility and the Right Care Plan facility by GPs and used to record risk relapse triggers and indicators for patient’s with mental health difficulties and risk of suicide/ self harm. This enables Out of Hours Services such as those operated by Derbyshire HealthCare United to access key risk information when they are called out of hours when the GP and the full GP records with this key information is not available. There appears to be action that can be taken by NHS England through the Clinical Commissioning Groups to educate GPs as to this facility.
” Open source report × Source evidence
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure shared understanding of care co-ordinator roles and Care Programme Approach responsibilities
Wider context from the report “1. The CMHT from the evidence I heard did not understand that the DCC Recovery Team is not following the Care Programme approach, neither are lead professionals from the DCC Recovery Team acting as care co-ordinators for the purposes of the Care Programme Approach [CPA]. I heard evidence that the Psychiatrist from the CMHT understood that the social worker from the DCC Recovery Team was Louise Henry’s Care coordinator for CPA purposes and was following the Care Programme Approach. I also heard evidence that when the services of the DCC Recovery Team and CMHT ceased to be an Integrated service the understanding of the psychiatrist had been that the DCC Recovery Team workers would be following the CPA. I heard evidence from DCC Recovery Team that this was not the case and that they were not following the CPA or acting as the care co-ordinator for the purposes of CPA but instead worked to the Self Directed Support framework. It is important that the CMHT understand the roles and responsibilities of the Lead professional from the DCC Recovery Team and that they are not following the Care Programme approach or acting as the care co-ordinator. It is of concern that workers from the CMHT and DCC Recovery Team who often are involved in providing multi agency mental health services and joint working to patients misunderstand each others roles, responsibilities and processes. The care co-ordinator is a key role in the management of a patient with mental health difficulties and it is important that there is no ambiguity in respect of who is acting in this capacity.
” Open source report × Source evidence
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of discharge letters to identify mental health relapse risks and indicators
Wider context from the report “2. That both the CMHT and the Recovery Team of DCC ensure that when discharging patients all necessary processes and procedures indicated in policies are followed by the lead professional and / or care co-ordinator and that discharge letters sent to GPs and to patients identify risk relapse triggers and indicators to ensure re-assessment if there are signs of deterioration in mental health and speedy referral back to secondary mental health services if required . My concern is that the processes and procedures indicated on discharge for Louise Henry were not followed and the confusion as to roles and responsibilities risks this re-occurring.
” Open source report × Source evidence
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to distinguish Recovery Team services operated by different agencies
Wider context from the report “3. There is a misunderstanding in respect of the Recovery Team from DCC and the Recovery Team within the CMHT and potential for confusion between professionals and service users due to there being 2 services operating under the title “Recovery Team” operated by different agencies namely DCC and the CMHT.
” Open source report × Source evidence
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to follow required patient discharge processes and procedures
Wider context from the report “2. That both the CMHT and the Recovery Team of DCC ensure that when discharging patients all necessary processes and procedures indicated in policies are followed by the lead professional and / or care co-ordinator and that discharge letters sent to GPs and to patients identify risk relapse triggers and indicators to ensure re-assessment if there are signs of deterioration in mental health and speedy referral back to secondary mental health services if required. My concern is that the processes and procedures indicated on discharge for Louise Henry were not followed and the confusion as to roles and responsibilities risks this re-occurring.
” Open source report
23 Jun 2015 Steven Curtis · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 1 Safety hazard posed by Maplin N19KJ telescopic ladders 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
Steven Curtis · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Steven Curtis fell from a telescopic ladder while inspecting a roof and was admitted to hospital, where he underwent treatment before complications and subsequent death. The principal concern was the safety and origin of the ladder, including whether it was one of approximately 43,000 N19KJ ladders sold by Maplin before withdrawal and whether further investigation could establish its source.
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Safety hazard posed by Maplin N19KJ telescopic ladders
Wider context from the report “I said at the Inquest that I would adopt a two-stage approach. Firstly, that I would write to Derbyshire Trading Standards in view of the existing investigation concerning the Maplin N19KJ telescopic ladder. I refer to the letter from Graham Morgan dated 1 June 2015 and the Investigation Report. I see that there was a primary offence in relation to the safety of the ladder and two ancillary offences which led to a caution. The ladders were withdrawn from sale by Maplin. However, I understand that Maplin sold approximately 43,000 of the ladders in the UK before withdrawal. The matter of concern is in relation to the safety of these ladders if it transpires that the accident ladder was supplied by Maplin. To be fair to Maplin, it appears on the existing evidence that there are no other reported cases of catastrophic failures such as this with the N19KJ ladder.
” 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