12 Feb 2026 James Fitzpatrick · Prevention of Future Deaths report Dorset
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Concerns raised 3 Failure to ensure accurate and complete handover information View source Lack of written national guidance for handovers across healthcare settings View source Lack of written local guidance for undertaking and recording handovers View source
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AI-generated summary
James Fitzpatrick · 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
James Fitzpatrick, an 89-year-old man with decompensated heart failure and respiratory illness, became unresponsive after coughing and was found with food material in his mouth; his death was confirmed on 14 February 2024. The principal concerns were the lack of written national and local guidance for care handovers, and the risk that incomplete or incorrect handover information could affect patient care and contribute to a future death.
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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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate and complete handover information
Wider context from the report “(4) Two weeks prior to his death, Jim was moved to another ward within Alderney Hospital. There was a verbal handover undertaken which was recorded in the electronic patient records. No written handover was provided. The patient records referred to him being a “high risk of choking” and “on an unofficial soft diet”. This information was not true and was not recorded anywhere else in his records or risk assessments.
(5) Further evidence was given that at the time of Jim’s death there were a number of agency workers at Alderney Hospital, and they would rely on information provided to them at the start of their shift during the handover as they would not have time to go through each patient’s records to appraise themselves of the patient’s history and risks. A daily written handover sheet was provided at the beginning of each shift which would be updated during the day, however from the daily handover sheet provided to the Court for the day of Jim’s death, pertinent general information about Jim was missing from that handover sheet .
(6) The lack of written local and national guidance on the handover of a patient’s care creates a risk that incorrect or incomplete information can be passed to those caring for an individual which may impact upon the patient’s care and may lead to a future death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of written national guidance for handovers across healthcare settings
Wider context from the report “(1) There is a lack of written national guidance on how handovers between Doctors, Nurses and support staff should be undertaken either when a patient is moved between wards or hospitals, or when there is the handover to staff starting a shift who will be taking over the care of the person. Whilst it is acknowledged that each Trust has different policies and procedures in place, there is no generic national guidance to assist in ensuring relevant, pertinent and critical information is passed on to those who will be caring for the patient .
(2) Evidence was provided that national guidance currently exists in England and Wales for handovers relating to emergency care in acute hospitals, however there is no other guidance for other healthcare settings as to what a handover should include or how it should be undertaken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of written local guidance for undertaking and recording handovers
Wider context from the report “(3) Within DHUFT there is a lack of written guidance or policy as to how handovers should be undertaken and recorded by those working within the Trust .
” 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 Strengthen Good medical practice standards on continuity of care, information sharing, safe delegation and handover responsibilities.
Verbatim wording from the response “We recently completed a review of Good medical practice and the latest version (effective from 30 January 2024) was developed following an extensive public consultation process, involving members of the professions, the public, patients and other stakeholders. Analysis of the responses revealed that team working and continuity of care were priority themes and we strengthened the guidance in several areas to reflect this.” Source location 2026-0087 - Response from General Medical 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 Analyse consultation responses on Leadership and management and Raising concerns guidance.
Verbatim wording from the response “Our review of our guidance on Leadership and management and Raising concerns” Source location 2026-0087 - Response from General Medical 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 updated Leadership and management and Raising concerns guidance following the consultation.
Verbatim wording from the response “We have recently conducted a public consultation on these two pieces of guidance, and we are in the process of analysing the results. We intend to publish a report on the findings of the consultation later this year and will go on to develop an updated version of the guidance. We will consider the concerns raised in your report as part of this review process.” Source location 2026-0087 - Response from General Medical 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 Deliver outreach talks and workshops supporting implementation of professional standards, including communication, teamwork, information sharing and patient safety.
Verbatim wording from the response “Our Outreach teams across the UK regularly give talks and run workshops on the implementation of our guidance to our registrants. These workshops will often highlight the importance of communication, teamwork, ensuring effective information sharing and prioritising patient safety.” Source location 2026-0087 - Response from General Medical 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 opportunities to promote handover, continuity of care, teamwork and communication expectations through Outreach when promoting updated guidance.
Verbatim wording from the response “We will explore opportunities to promote our expectations regarding handovers, continuity of care, team working and communication with our Outreach team as we look to promote and implement our updated guidance on Leadership and management and Raising concerns.” Source location 2026-0087 - Response from General Medical 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 Clinical standards and clinical advice on handovers fall outside the respondent’s professional-regulatory functions.
Verbatim wording from the response “We do not set clinical standards or give clinical advice to our registrants. This is the role of a wide range of other bodies, such as the National Institute for Health and Care Excellence (NICE), government health departments and the medical royal colleges. I can see that you have sent your report to NICE.” Source location 2026-0087 - Response from General Medical 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 Clinical standards and advice on handovers are assigned to bodies such as NICE, government health departments and medical royal colleges.
Verbatim wording from the response “We do not set clinical standards or give clinical advice to our registrants. This is the role of a wide range of other bodies, such as the National Institute for Health and Care Excellence (NICE), government health departments and the medical royal colleges. I can see that you have sent your report to NICE.” Source location 2026-0087 - Response from General Medical Council
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12 Nov 2025 Christopher Graham Ayerst SAMPSON · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 7 Absence of a national road safety strategy View source Insufficient awareness among medical professionals of guidance on notifying the DVLA View source Uncertainty about the effectiveness of mechanisms for doctors to report patients' health issues to the DVLA View source Failure of medical professionals to report patients' health issues to the DVLA View source Failure to ensure drivers understand how and when to notify the DVLA of medical conditions View source Failure of drivers to self-report medical conditions to the DVLA View source Lack of published statistical evidence on DVLA health-issue reporting mechanisms View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Christopher Graham Ayerst SAMPSON · 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
Christopher Graham Ayerst Sampson was a front-seat passenger in a Mazda that was struck by a Mercedes travelling at speeds exceeding 100 mph after its driver suffered an unexpected medical event. Christopher sustained unsurvivable injuries and was declared deceased at the scene. The principal concern was the risk of future deaths arising from drivers failing to self-report medical conditions to the DVLA, and uncertainty about the effectiveness and awareness of medical professionals’ reporting guidance.
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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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Absence of a national road safety strategy
Wider context from the report “5. Following scrutiny of those reports, it is apparent that the DVLA and Department of Transport previously called for evidence in 2023 seeking views on the current legislative basis for establishing whether a person was medically fit to drive. At that time, officials were considering what that evidence and considering policy options as part of the government’s road safety strategy which was being developed and the details would be provided, “in due course”.
6. Two years later from that call for evidence, and still no national strategy has been announced . I understand that in August 2025 His Majesty's Government announced that a new Road Safety Strategy would be published in the Autumn of 2025. However, we are now in the depths of November and there is no sign currently of any Road Safety Strategy being published .
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient awareness among medical professionals of guidance on notifying the DVLA
Wider context from the report “7. I am aware that the DVLA publishes guidance on GOV.UK called “Assessing fitness to drive: a guide for medical professionals” to support healthcare professionals (https://www.gov.uk/government/publications/assessing-fitness-to-drive-a-guide-for-medical-professionals). What is unclear, however, is whether a) that guidance is well known amongst medical professionals, and b) whether that process is an effective mechanism for doctors to report patients with health issues, as there does not appear to be any published statistical evidence on the issue.
8. I am also aware that The General Medical Council (GMC) and the General Optical Council (GOC) offer guidance about notifying DVLA when the person cannot or will not exercise their own legal duty to do so. Again, it is unclear whether a) that guidance is well known amongst medical professionals , and b) whether that process is an effective mechanism for doctors to report patients with health issues, as there does not appear to be any published statistical evidence on the issue.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about the effectiveness of mechanisms for doctors to report patients' health issues to the DVLA
Wider context from the report “7. I am aware that the DVLA publishes guidance on GOV.UK called “Assessing fitness to drive: a guide for medical professionals” to support healthcare professionals (https://www.gov.uk/government/publications/assessing-fitness-to-drive-a-guide-for-medical-professionals). What is unclear, however, is whether a) that guidance is well known amongst medical professionals, and b) whether that process is an effective mechanism for doctors to report patients with health issues, as there does not appear to be any published statistical evidence on the issue.
8. I am also aware that The General Medical Council (GMC) and the General Optical Council (GOC) offer guidance about notifying DVLA when the person cannot or will not exercise their own legal duty to do so. Again, it is unclear whether a) that guidance is well known amongst medical professionals, and b) whether that process is an effective mechanism for doctors to report patients with health issues, as there does not appear to be any published statistical evidence on the issue.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure of medical professionals to report patients' health issues to the DVLA
Wider context from the report “9. Drivers may not self-report medical conditions due to a variety of reasons. This can be due to a lack of understanding, insight, or simply because someone has not explicitly told them what to do or how to do it. There are then those who are reckless and knowingly avoid notifying the DVLA of a health condition when explicitly told to do so - either through arrogance, pride or through fear of losing employment. The end result is the same: people are dying needlessly on our roads due to people who, legally, should not be on our roads.
10. There is a risk of future deaths occurring where drivers do not self-refer their conditions to the DVLA, or where medical professionals do not report those health issues to protect the wider public .
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure drivers understand how and when to notify the DVLA of medical conditions
Wider context from the report “9. Drivers may not self-report medical conditions due to a variety of reasons. This can be due to a lack of understanding, insight, or simply because someone has not explicitly told them what to do or how to do it . There are then those who are reckless and knowingly avoid notifying the DVLA of a health condition when explicitly told to do so - either through arrogance, pride or through fear of losing employment. The end result is the same: people are dying needlessly on our roads due to people who, legally, should not be on our roads.
10. There is a risk of future deaths occurring where drivers do not self-refer their conditions to the DVLA, or where medical professionals do not report those health issues to protect the wider public.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure of drivers to self-report medical conditions to the DVLA
Wider context from the report “9. Drivers may not self-report medical conditions due to a variety of reasons. This can be due to a lack of understanding, insight, or simply because someone has not explicitly told them what to do or how to do it. There are then those who are reckless and knowingly avoid notifying the DVLA of a health condition when explicitly told to do so - either through arrogance, pride or through fear of losing employment. The end result is the same: people are dying needlessly on our roads due to people who, legally, should not be on our roads.
10. There is a risk of future deaths occurring where drivers do not self-refer their conditions to the DVLA , or where medical professionals do not report those health issues to protect the wider public.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of published statistical evidence on DVLA health-issue reporting mechanisms
Wider context from the report “7. I am aware that the DVLA publishes guidance on GOV.UK called “Assessing fitness to drive: a guide for medical professionals” to support healthcare professionals (https://www.gov.uk/government/publications/assessing-fitness-to-drive-a-guide-for-medical-professionals). What is unclear, however, is whether a) that guidance is well known amongst medical professionals, and b) whether that process is an effective mechanism for doctors to report patients with health issues, as there does not appear to be any published statistical evidence on the issue.
8. I am also aware that The General Medical Council (GMC) and the General Optical Council (GOC) offer guidance about notifying DVLA when the person cannot or will not exercise their own legal duty to do so. Again, it is unclear whether a) that guidance is well known amongst medical professionals, and b) whether that process is an effective mechanism for doctors to report patients with health issues, as there does not appear to be any published statistical evidence on the issue.
” 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 Collaborate with partner organisations and medical defence bodies to support appropriate responses when patients may be unfit to drive.
Verbatim wording from the response “• Working in collaboration with other organisations who help us engage with registrants. As part of our work to develop and consult on the confidentiality guidance as part of the last review in 2016, we hosted two roundtables with partner organisations to support doctors to respond appropriately when patients may not be fit to drive. We also worked closely with medical defence bodies to develop materials they produced for their members on this issue.” Source location Response from General Medical 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 accessible learning materials, including a case study and video, on fitness-to-drive responsibilities.
Verbatim wording from the response “• Developing accessible learning materials, including a case study and a video to support awareness of the expectations in this area.” Source location Response from General Medical Council
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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 Raise awareness of fitness-to-drive confidentiality guidance through registrant talks, workshops and published communications.
Verbatim wording from the response “• Raising awareness of the guidance through our direct communication and engagement channels with doctors, PAs and AAs. Our outreach teams across the UK regularly give talks and run workshops on confidentiality and making decisions about disclosing information in the public interest to our registrants. These workshops will often highlight the importance of sharing information about a patient's medical condition(s) with the DVLA/DVA where necessary. We have also previously published several blogs, including one from the DVLA’s Senior Medical Advisor in 2015 which outlined the DVLA’s processes and reinforced our advice on doctors’ responsibilities.” Source location Response from General Medical Council
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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 joint awareness work with the General Optical Council, including shared messages and coordinated communications timing.
Verbatim wording from the response “We have begun planning for using our communication channels, such as the e-newsletters we send out regularly to all our registrants and to responsible officers, to run a new targeted awareness campaign for the guidance in the new year. As part of this, we have spoken to colleagues in the General Optical Council to explore the possibilities for joint working, including how we might collaborate on some shared messages to our registrants, and coordinate timing to maximise the impact of any communications activity. We will continue to progress this work over the coming weeks.” Source location Response from General Medical Council
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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 Embed DVLA/DVA notification expectations in education and training requirements for registrants.
Verbatim wording from the response “• Making sure our expectations are made clear within the education and training of the people on our register. Although the detailed content of curricula is the responsibility of schools, royal colleges and faculties, we set the expected outcomes based on Good medical practice, which includes duties to protect and promote the health of patients and the public. Specifically, the DVLA/DVA notification processes are highlighted in the ‘national legislative requirements’ section of the Generic professional capabilities framework (see domain 3). This framework is embedded in postgraduate training curricula, meaning that all specialty training programmes need to cover these requirements.” Source location Response from General Medical Council
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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 and refresh outreach materials for 2026 onward, including wider references to fitness-to-drive guidance and responsibilities.
Verbatim wording from the response “Finally, our outreach teams are currently looking at their materials to see whether and how these might be refreshed for 2026 and beyond. This includes looking at opportunities to include further references to the fitness to drive guidance and a reminder of responsibilities in this area across a wider range of sessions, including our free Welcome to UK practice sessions that we run with doctors who are new to practice in the UK.” Source location Response from General Medical Council
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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 Plan and progress a targeted awareness campaign through registrant and responsible-officer communication channels.
Verbatim wording from the response “We have begun planning for using our communication channels, such as the e-newsletters we send out regularly to all our registrants and to responsible officers, to run a new targeted awareness campaign for the guidance in the new year. As part of this, we have spoken to colleagues in the General Optical Council to explore the possibilities for joint working, including how we might collaborate on some shared messages to our registrants, and coordinate timing to maximise the impact of any communications activity. We will continue to progress this work over the coming weeks.” Source location Response from General Medical Council
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 Schools, royal colleges and faculties are responsible for the detailed content of curricula covering fitness-to-drive notification requirements.
Verbatim wording from the response “• Making sure our expectations are made clear within the education and training of the people on our register. Although the detailed content of curricula is the responsibility of schools, royal colleges and faculties, we set the expected outcomes based on Good medical practice, which includes duties to protect and promote the health of patients and the public. Specifically, the DVLA/DVA notification processes are highlighted in the ‘national legislative requirements’ section of the Generic professional capabilities framework (see domain 3). This framework is embedded in postgraduate training curricula, meaning that all specialty training programmes need to cover these requirements.” Source location Response from General Medical Council
Open published response
24 Feb 2025 Pamela Anne Marking · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 10 Failure to clearly explain and differentiate the Physician Associate role from medically qualified practitioners View source Lack of updated guidelines for rapid sequence induction of anaesthesia in emergency surgery View source Inadequate medical supervision of Physician Associates managing undifferentiated Emergency Department patients View source Unavailability of promptly accessible suction for aspiration during rapid sequence induction View source Failure to inform patients and families that Physician Associates are not medically qualified View source Lack of public understanding of the Physician Associate role View source Lack of guidance on TIVA dosing and timing for rapid sequence induction View source Lack of updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction View source Failure to prevent Physician Associates undertaking roles outside their competency View source Lack of regulated scope-of-practice guidance and recognised training for Physician Associates View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Pamela Anne Marking · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Pamela Anne Marking was admitted with abdominal symptoms, was diagnosed with a nosebleed by a Physician Associate and discharged without medical review or direct medical supervision. She later returned with small bowel obstruction caused by an incarcerated femoral hernia and aspirated feculent fluid during induction of anaesthesia for emergency surgery, subsequently dying from respiratory failure and sepsis. The concerns included the Physician Associate’s role, supervision and scope of practice, and the absence of updated guidance for rapid sequence induction, TIVA and airway protection.
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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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly explain and differentiate the Physician Associate role from medically qualified practitioners
Wider context from the report “1. The term ‘Physician Associate’ is misleading to the public
Mrs Marking’s son was under the mistaken belief that the Physician Associate was a doctor by this title in circumstances where no steps were taken by the Emergency Department or the Physician Associate to explain or clearly differentiate their role from that of medically qualified practitioners .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of updated guidelines for rapid sequence induction of anaesthesia in emergency surgery
Wider context from the report “6. Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery
Mrs Marking required a rapid sequence induction to protect her airway from aspiration of bowel contents as a consequence of small bowel obstruction. The consultant anaesthetist gave evidence that the ‘traditional’ use of consecutive syringes of induction agent and muscle relaxant was obsolete, and it was common practice locally and nationally to routinely undertake a RSI with Total Intravenous Anaesthesia, in the absence of updated local or national guidelines to support this practice .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate medical supervision of Physician Associates managing undifferentiated Emergency Department patients
Wider context from the report “5. Lack of guidelines for direct supervision and consideration of an appropriate level of autonomy for Physician Associates
Whilst there were discussions with the ‘supervising’ consultant the Physician Associate was effectively acting independently in the diagnosis, treatment, management and discharge of Mrs Marking without independent oversight by a medical practitioner . This gives rise to a concern that inadequate supervision or excessive delegation of undifferentiated patients in the Emergency Department to Physician Associates compromises patient safety.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of promptly accessible suction for aspiration during rapid sequence induction
Wider context from the report “8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic
Evidence was heard that cricoid pressure was ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to inform patients and families that Physician Associates are not medically qualified
Wider context from the report “3. The right of patients and family to seek a second opinion
The lack of public knowledge that a Physician Associate is not medically qualified has the potential to hinder requests by patients and their relatives who would wish to seek an opinion from a medical practitioner. It also raises issues of informed consent and protection of patient rights if the public are not aware or have not been properly informed that they are being treated by a Physician Associate rather than a medically qualified doctor.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of public understanding of the Physician Associate role
Wider context from the report “2. Lack of public understanding of the role of Physician Associate
Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on TIVA dosing and timing for rapid sequence induction
Wider context from the report “7. Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI
Other than empirically increasing the rate of infusion of TIVA agents (Propofol and Remifentanil) no evidence was forthcoming as to the target range required to ensure and confirm an adequate depth of anaesthesia for patients or the length of time required prior to and following the administration of a muscle relaxant (Rocuronium) to facilitate intubation. This is despite TIVA being known to provide a slower onset of anaesthesia and approximately 50% of all anaesthetic related deaths are due to aspiration (NAP 4).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction
Wider context from the report “8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic
Evidence was heard that cricoid pressure was ineffective it was not routinely applied for a RSI intubation . After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent Physician Associates undertaking roles outside their competency
Wider context from the report “2. Lack of public understanding of the role of Physician Associate
Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of regulated scope-of-practice guidance and recognised training for Physician Associates
Wider context from the report “4. Lack of national and local guidelines and regulation of the scope of practice for a Physician Associate
A diagnosis of epistaxis was made by the Physician Associate without appreciating the relevance of the vomiting and lower abdominal discomfort and in the absence of understanding the need to undertake palpation of the groins in an abdominal examination in a patient who was unable to give a proper clinical history because of short term memory loss. No evidence was presented that the management of Mrs Marking was subject to a reflective practice review. Given their limited training and in the absence of any national or local recognised hospital training for Physician Associates once appointed , this gives rise to a concern they are working outside of their capabilities .
” Open source report
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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 publish website materials supporting doctors who supervise physician associates and applying relevant supervision guidance.
Verbatim wording from the response “We are currently in the final stages of developing materials for our website, to support doctors who are supervising PAs, and help them to apply the principles in our guidance within their practice. This material, due to be published in spring, brings together all of our relevant standards, expanding on these with further advice, as well as signposting to a range of other resources published by others.” Source location Response from General Medical Council
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide feedback on specialist professional bodies’ draft guidance concerning physician associate scope of practice.
Verbatim wording from the response “We believe that the royal colleges and other specialist professional bodies have the level of clinical expertise required to provide more detailed guidance on PA scope of practice within their specialty areas. We are grateful for the work that royal colleges have undertaken so far in developing” Source location Response from General Medical Council
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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 Issue updated clinical-governance guidance supporting supervision, board-level responsibility and local governance of physician associates and anaesthesia associates.
Verbatim wording from the response “To support employers, we have issued our updated guidance Effective clinical governance to support revalidation. It emphasises that PAs and AAs must be supervised and recommends that organisations identify an individual at Board level to be responsible for PAs and AAs. It also suggests establishing local processes to govern how these professionals are deployed and supervised. The work of a PA or AA must be overseen by a named senior doctor, and they must work together to agree appropriate limitations to their practice.” Source location Response from General Medical Council
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 Clearly distinguish doctors, physician associates and anaesthesia associates on public registers and in register searches.
Verbatim wording from the response “Now that regulation is in effect, the registers on our website are clearly marked to distinguish between the three professions we regulate. A prefix is used for PA and AA reference numbers, which provides a clear distinction between those two professions and doctors. In addition, each profession type is prominently labelled on our public-facing registers, and in search functions. This means that when patients search our registers it will be very clear whether an individual is a doctor, a PA or an AA.” Source location Response from General Medical Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual competence and clinical context vary, so GMC standards do not impose fixed ceilings on what registered PAs may do.
Verbatim wording from the response “objectively by passing our two-part assessment. Our standards do not impose ceilings on what individual doctors, PAs and AAs can do once registered. This is because we recognise that competence will vary by individual and is shaped by their supervised training and experience, and the clinical context of their work.” Source location Response from General Medical Council
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 Employers, clinical leaders and supervisors must determine PAs’ permitted activities and required supervision through local clinical governance.
Verbatim wording from the response “Robust systems of clinical governance are important to ensure a consistent approach to the safe and effective deployment of PAs and AAs. Employers have a clinical governance responsibility to ensure that all their employees are appropriately trained and competent to do the activities they are tasked with. It is an employer’s responsibility, with the involvement of clinical leaders and supervisors, to determine which activities or specific tasks an individual can carry out and what level of supervision is required.” Source location Response from General Medical Council
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 Royal colleges and specialist professional bodies should provide detailed specialty-specific guidance on physician associate scope of practice.
Verbatim wording from the response “We believe that the royal colleges and other specialist professional bodies have the level of clinical expertise required to provide more detailed guidance on PA scope of practice within their specialty areas. We are grateful for the work that royal colleges have undertaken so far in developing” Source location Response from General Medical Council
Open published response
22 Jan 2025 Fahmida Khanam · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1 Failure to avoid doctors treating close relatives View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Fahmida Khanam · 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
Fahmida Khanam died on 12 November 2024, and a post-mortem attributed her death to natural causes. The report states that her husband had been treating her, and raises the concern that a doctor should not treat a close relative; it does not suggest suspicious conduct.
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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to avoid doctors treating close relatives
Wider context from the report “The matter is reported as it is understood to be a cardinal principle that a doctor should not treat a close relative .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The guidance does not prohibit doctors from treating close relatives; it advises avoiding this where possible, subject to professional judgement and circumstances.
Verbatim wording from the response “On the specific concern that you highlight, in paragraph 97 of that guidance, we say ‘You must, wherever possible, avoid providing medical care to yourself or anyone with whom you have a close personal relationship’. You go on to point registrants to the more detailed guidance on Good practice in proposing, prescribing, providing and managing medicines and devices and in particular paragraphs 66 to 68 regarding record keeping and the issues around prescribing controlled drugs.” Source location Response from General Medical Council
Open published response
31 Jul 2024 Susan Pollitt · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 6 Failure to ensure clear identification and understanding of the Physician Associate role View source Lack of a clear mechanism for reporting concerns about individual Physician Associates View source Failure to require employers to verify Physician Associate registration View source Failure of competency assessments to cover the wider aspects of care for ascetic drain insertion View source Lack of regulatory oversight of Physician Associates View source Lack of a national framework for training, supervision and competence of Physician Associates View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Susan Pollitt · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Susan Pollitt was admitted to hospital after collapsing at home and developed ascites during her admission. An ascitic drain was inserted, remained in place for 21 hours, and was clamped; she developed bacterial peritonitis and died on 16 July 2023. The principal concerns included the lack of regulatory oversight and national training and competency frameworks for Physician Associates, and limited understanding of their role and responsibilities in managing ascitic drains.
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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clear identification and understanding of the Physician Associate role
Wider context from the report “4. There remains limited understanding and awareness of the role of a Physician Associate both amongst medical colleagues, patients and their families. The lack of a distinct uniform and the title “Physician” gives rise to confusion as to whether the practitioner is a doctor.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear mechanism for reporting concerns about individual Physician Associates
Wider context from the report “2. The Physicians Associate Managed Voluntary Register held by the Faculty of Physician Associates (FPA) is voluntary. Whilst employers are encouraged to check the register there is no duty to do so, nor is it clear how the FPA would be made aware of any concerns relating to an individual Physician Associate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to require employers to verify Physician Associate registration
Wider context from the report “2. The Physicians Associate Managed Voluntary Register held by the Faculty of Physician Associates (FPA) is voluntary. Whilst employers are encouraged to check the register there is no duty to do so , nor is it clear how the FPA would be made aware of any concerns relating to an individual Physician Associate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure of competency assessments to cover the wider aspects of care for ascetic drain insertion
Wider context from the report “5. In June 2022 the Physicians Associate had been signed off as competent for the insertion of ascetic drains. This sign off was completed by a liver nurse specialist using a competency form which was provided by the FPA. Whilst the competency form assessed the technical aspect of placing the drain, it did not include competency around the wider aspects of care such as taking consent, risk factors and after care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory oversight of Physician Associates
Wider context from the report “1. There is no regulatory body with oversight of Physician Associates. It is understood that this is currently the subject of a consultation by the General Medical Council.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a national framework for training, supervision and competence of Physician Associates
Wider context from the report “3. There is no national framework as to how Physician Associates should be trained, supervised and deemed competent. This is placing both patients, Physicians Associates and their employers at risk. The Court heard that since the death of Mrs Pollitt the Northern Care Alliance have put in place a local trust framework. Unlike all other clinical roles there is no national guidance save for very recent guidance issued by the British Medical Association (March 2024).
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish guidance supporting physician associate students and course providers pending implementation of statutory regulation.
Verbatim wording from the response “Regarding PA education and training - once regulation begins in December 2024, we’ll have powers to set the standards for course providers and regularly check that they’re being met. We have already published a range of guidance to support PAs student PAs and course providers pending the implementation of regulation. From December 2024 we will be able to formally approve courses and curricula to ensure that PAs will have the clinical knowledge and skills needed to work safely once they qualify.” Source location Response from GMC
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 Finalise updated guidance for physician associate students on professional standards and the process for approving curricula.
Verbatim wording from the response “In preparation for the start of regulation we have already asked course providers to update their courses, including their syllabus and assessments, using the relevant curriculum as a guide, and we are checking that this has been done through our education quality assurance process. We are also finalising updated guidance for PA students on professional standards and the process for approving PA curricula.” Source location Response from GMC
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 Implement alphabetical prefixes and prominent profession-type labelling on public-facing registers for physician associates and anaesthesia associates.
Verbatim wording from the response “In March this year we also announced that we would implement an alphabetical prefix for PA and AA GMC reference numbers and ensure the prominent labelling of profession type on our public-facing registers. This means that in future when patients search our registers it will be very clear whether an individual is a doctor, a PA or an AA not only because of the use of a prefix for PAs and AAs but also because the face of the register will actually spell out in full the professional title of each individual (‘Doctor’, ‘Physician Associate’, ‘Anaesthesia Associate’).” Source location Response from GMC
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 Approve physician associate courses and curricula once regulation begins, ensuring they meet required clinical knowledge and skills standards.
Verbatim wording from the response “Regarding PA education and training - once regulation begins in December 2024, we’ll have powers to set the standards for course providers and regularly check that they’re being met. We have already published a range of guidance to support PAs student PAs and course providers pending the implementation of regulation. From December 2024 we will be able to formally approve courses and curricula to ensure that PAs will have the clinical knowledge and skills needed to work safely once they qualify.” Source location Response from GMC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require course providers to update syllabuses and assessments, and check those changes through the education quality assurance process.
Verbatim wording from the response “In preparation for the start of regulation we have already asked course providers to update their courses, including their syllabus and assessments, using the relevant curriculum as a guide, and we are checking that this has been done through our education quality assurance process. We are also finalising updated guidance for PA students on professional standards and the process for approving PA curricula.” Source location Response from GMC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Begin statutory regulation of physician associates and anaesthesia associates from December 2024.
Verbatim wording from the response “In 2017, the Department of Health and Social Care (DHSC) consulted on which healthcare regulator would be most suitable to regulate one, some, or all the medical associate professions, which include PAs and AAs. Surgical care practitioners are the third profession in this group but are not included in those we will regulate. Following the consultation, the Government determined the GMC was most appropriate and formally asked us to take on the regulation of PAs and AAs which we agreed to do. The UK and Scottish parliaments approved the legislation (Anaesthesia Associates and Physician Associates Order 2024) earlier this year and it has been granted Royal Assent. This means the GMC will become the regulator of PAs and AAs from December 2024 and, from December 2026, they will have protected titles in law (‘Physician Associate’ and ‘Anaesthesia Associate’).” Source location Response from GMC
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 Support royal colleges’ development of supervision and competency guidance, while encouraging consistent alignment across guidance produced by colleges and NHS employers.
Verbatim wording from the response “Finally, we have been supporting the work that individual royal colleges, and the Academy of Medical Royal Colleges, are currently leading on developing a range of guidance on supervision and how PAs can safely develop their skills and competencies over time once they have qualified and registered with us. The Royal College of Physicians is also concentrating on their guidance and the Royal College of General Practitioners plans to do so shortly. We are also encouraging colleges, NHS employers and others to ensure that all guidance being produced is aligned and consistent so as not to cause confusion for employers, supervisors or PAs themselves.” Source location Response from GMC
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 Strongly encourage physician associates to join the GMC register as soon as possible.
Verbatim wording from the response “We anticipate that employers will make GMC registration a condition for their PAs in the same way as they have done up to now in relation to voluntary registration. Although GMC registration doesn’t become a legal requirement for practice until December 2026, we will strongly encourage all PAs to join our register as soon as possible.” Source location Response from GMC
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 Publish advice for doctors supervising physician associates and update the clinical governance handbook on their deployment and supervision.
Verbatim wording from the response “We have also published our own advice for doctors who supervise PAs, and earlier this year we updated our clinical governance handbook to set out our expectation that organisations who employ PAs should make appropriate arrangements for their deployment and supervision.” Source location Response from GMC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider consultation responses and finalise the rules, professional standards and guidance required to implement associate regulation.
Verbatim wording from the response “We recently consulted on the rules, standards and guidance needed to implement the legislation that gives us the power to regulate PAs and we’re now considering the responses so that we can finalise our approach. Once regulation begins, we will have powers to:” Source location Response from GMC
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 Responsibility for distinct uniforms to help patients distinguish professionals rests with the NHS and employers.
Verbatim wording from the response “The issue you raise about the need for distinct uniforms to help patients distinguish between professionals is for the NHS and employers to address.” Source location Response from GMC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The GMC has no role in determining the investigatory or disciplinary processes of the Faculty of Physician Associates’ voluntary register.
Verbatim wording from the response “I will leave it to the FPA to explain how they currently deal with concerns raised about a member of their voluntary register. The GMC currently has no power to investigate concerns raised about PAs as they are not yet regulated by us, and we have no role in determining the investigatory and disciplinary processes of the FPA. However, we can and will look at any outstanding concerns about an individual PA’s fitness to practise when considering their application for registration with us from December this year.” Source location Response from GMC
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 Questions about clinical governance, drain use, ward placement, delegation, supervision and local policy are better explained by the trust.
Verbatim wording from the response “Regulation is an important part of patient safety, but it alone cannot prevent future deaths. Good clinical governance by healthcare providers remains the most important factor. Your report raises significant questions that cannot be answered by those to whom the report is currently addressed, and are better explained by the trust:” Source location Response from GMC
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The GMC currently has no power to investigate concerns about physician associates because they are not yet regulated by it.
Verbatim wording from the response “I will leave it to the FPA to explain how they currently deal with concerns raised about a member of their voluntary register. The GMC currently has no power to investigate concerns raised about PAs as they are not yet regulated by us, and we have no role in determining the investigatory and disciplinary processes of the FPA. However, we can and will look at any outstanding concerns about an individual PA’s fitness to practise when considering their application for registration with us from December this year.” Source location Response from GMC
Open published response
Concerns raised 1 Failure to measure the incision from the insular to the Temporal Horn at appropriate intra-operative times View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tracy Gambrill · 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
Tracy Gambrill underwent neurosurgery on 7 November 2016 and sustained serious brain injury after excessively deep incisions were made while locating the temporal horn. She died in hospital on 19 November 2016. The principal concern was that it was not current and expected practice to measure the incision from the insular to the temporal horn at appropriate times during the operation.
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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to measure the incision from the insular to the Temporal Horn at appropriate intra-operative times
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
Each of the three surgical incisions were far too deep considering the average distance between the insular and the Temporal Horn. Only the second incision was measured intra operatively using a cannula and this was after the completion of the incision. From the evidence it is apparent that this operation is undertaken with surgeons relying on anatomical landmarks and head position to perform the procedure safely. The inquest did hear from an expert neurosurgical witness whose practice it was to measure the length of his incisions intra-operatively at appropriate times. This practice resulted in him having aborted an operation after failing to find the Temporal Horn within expected limits. Post-operatively he discovered that the patient’s head had moved from the correct position.
I am concerned that it remains the position that it is not current and expected practice to measure the incision from the insular to the Temporal Horn at appropriate times during the operation.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clinical procedure guidance falls outside the respondent’s role, which provides only high-level professional standards.
Verbatim wording from the response “You raise the concern in your report that it is not current and expected practice for surgeons to measure the incision from the insula to the temporal horn at appropriate times during a transsylvian amygdalohippocampectomy. We do not provide guidance on clinical procedures, and other organisations who hold the expert clinical knowledge will be better placed to address your concern more directly, but I will explain where our standards and guidance will support actions taken to address your concern.” Source location Response from General Medical Council
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 Queries about specific procedure details should be directed to NICE, medical royal colleges, or specialty bodies.
Verbatim wording from the response “As the standards we set for medical education and practice don’t describe the details of specific procedures, we would refer queries on these to the National Institute for Clinical Excellence (NICE), medical royal colleges or specialty bodies. I note that The Society of British Neurological Surgeons (SBNS) has already responded to your concern with immediate action, writing to all SBNS members, asking them to recognise the importance of measuring depth intraoperatively, and empowering them to abort surgery when findings are not consistent with expectations.” Source location Response from General Medical Council
Open published response
Concerns raised 7 Failure to identify the need for genetic testing before the Pathology report View source Chronic shortage of Paediatric Pathologists View source Limited use of molecular autopsy after sudden death in childhood View source Failure of the SUDIC Protocol to reflect the development of molecular autopsy View source Limited use of molecular autopsy to detect familial genetic variants View source Insufficient time for timely Coronial and Forensic Paediatric Pathology work View source Delays in Paediatric Pathology reports View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tyler Jay Ryan · 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
Tyler Jay Ryan, aged 11, was found collapsed in his bedroom on 12 February 2021 and died after resuscitation attempts. Genetic testing identified two RYR2 variants associated with CPVT, following earlier differing pathological opinions. The report raised concerns about delays in paediatric pathology reporting and the delayed identification of families who may need genetic testing, as well as the need for wider use of molecular autopsy and revision of the SUDIC Protocol.
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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to identify the need for genetic testing before the Pathology report
Wider context from the report “2. The delay in Paediatric Pathology Reports results in the delayed detection of the need for genetic testing amongst surviving siblings of children who die of Sudden Death in Childhood. Currently, it is not until the Pathologist provides a report that the need for genetic testing is identified . Reports can take up to two years to be filed.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Chronic shortage of Paediatric Pathologists
Wider context from the report “1. ████████ and ████████ each gave evidence that the delay in Paediatric Pathology reports is due to a chronic shortage in recruitment and retention of Paediatric Pathologists in the UK . This shortage is systemic. Currently only 50 out of 80 national vacancies for Paediatric Pathologists are filled . Coronial and Forensic work is undertaken by these Pathologists on a private basis, in addition to their NHS work. This provides insufficient time to carry out this work in a timely fashion. There is an acute shortage of Subspeciality Paediatric Pathologists, with just one Paediatric Orthopedic Pathologist undertaking Forensic and Coronial work in the UK .
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Limited use of molecular autopsy after sudden death in childhood
Wider context from the report “3. ████████ and ████████ gave evidence that more widespread use of molecular autopsy would assist in detecting genetic abnormalities in children who have died suddenly , leading to greater opportunities to prevent future deaths within their families and in other families.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the SUDIC Protocol to reflect the development of molecular autopsy
Wider context from the report “5. ████████ gave evidence that the development of the use of molecular autopsy calls for a revision of the SUDIC Protocol also known as the Kennedy Protocol .
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Limited use of molecular autopsy to detect familial genetic variants
Wider context from the report “4. ████████, Consultant Clinical Geneticist gave evidence that Tyler is, to date, the only human in history to have been found to have these two RYR2 variants which is significant to his family and to the wider scientific community. Greater use of molecular autopsy would save lives within families and in other families . The detection of these variants is directly relevant to others and the prevention of future deaths .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient time for timely Coronial and Forensic Paediatric Pathology work
Wider context from the report “1. ████████ and ████████ each gave evidence that the delay in Paediatric Pathology reports is due to a chronic shortage in recruitment and retention of Paediatric Pathologists in the UK. This shortage is systemic. Currently only 50 out of 80 national vacancies for Paediatric Pathologists are filled. Coronial and Forensic work is undertaken by these Pathologists on a private basis, in addition to their NHS work . This provides insufficient time to carry out this work in a timely fashion . There is an acute shortage of Subspeciality Paediatric Pathologists, with just one Paediatric Orthopedic Pathologist undertaking Forensic and Coronial work in the UK.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Delays in Paediatric Pathology reports
Wider context from the report “2. The delay in Paediatric Pathology Reports results in the delayed detection of the need for genetic testing amongst surviving siblings of children who die of Sudden Death in Childhood . Currently, it is not until the Pathologist provides a report that the need for genetic testing is identified. Reports can take up to two years to be filed .
” 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 Streamline registration processes through programmes currently underway.
Verbatim wording from the response “Beyond that, we also have number of programmes underway aimed at streamlining our registration processes. I recognise that none of this amounts to assurance about specific vacancies being filled. But I hope it shows our ongoing commitment to providing effective channels into the UK medical workforce.” Source location Response from General Medical Council
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 implement new pathways to the specialist register for suitably qualified doctors without UK-approved training.
Verbatim wording from the response “Particularly relevant here, perhaps, is the work we’re doing to make specialist registration more accessible to those who are suitably qualified, but who have not completed an approved training course in the UK. We have long sought, and have now obtained, a change to our legislation to make it less prescriptive about the evidence requirements to support an application for specialist” Source location Response from General Medical Council
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 Make registration pathways more flexible and accessible for doctors meeting required standards to join or remain in the UK medical workforce.
Verbatim wording from the response “However, we do have responsibility for the registration processes through which suitably qualified doctors obtain the legal right to practise in the UK, or (in the case of specialist registration) demonstrate that they have completed specialist training across all recognised specialties. How effective we are at managing those processes clearly does have a direct bearing on how readily the UK workforce can attract and absorb the doctors required to meet ever-increasing and more complex service needs. We’re committed, as a matter of priority, to making our registration pathways as flexible and accessible as we can for all those doctors who meet the required standards to join and remain in the UK medical workforce.” Source location Response from General Medical Council
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 Expand facilities and staffing to provide increased capacity for both parts of the PLAB test.
Verbatim wording from the response “In recent years we’ve invested in additional facilities and people to offer a record number of places in both parts of the Professional and Linguistic Assessments Board (PLAB) test, which is the means by which many international medical graduates can demonstrate their knowledge and skills for registration purposes. In 2022 over 14,000 doctors sat PLAB 1 and over 13,500 doctors sat PLAB 2, which were significant increases compared to previous years. The number of places this year is around 23,000 for PLAB 1 and 16,000 places for PLAB 2 respectively.” Source location Response from General Medical Council
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 Obtain and apply less prescriptive legislation governing evidence requirements for specialist registration applications.
Verbatim wording from the response “Particularly relevant here, perhaps, is the work we’re doing to make specialist registration more accessible to those who are suitably qualified, but who have not completed an approved training course in the UK. We have long sought, and have now obtained, a change to our legislation to make it less prescriptive about the evidence requirements to support an application for specialist” Source location Response from General Medical Council
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 UK governments and NHS bodies set the number of doctors trained in each specialty or subspecialty, not the regulator.
Verbatim wording from the response “The GMC, as the statutory regulator for the medical profession, does not have a direct role in the recruitment or retention of doctors across any specialty in the UK. This is exclusively a matter for the NHS in each of the four UK countries. Similarly, although we have responsibility for the oversight of postgraduate medical training, we have no role in determining how many doctors are trained in any specialty or subspecialty. These numbers are set by each of the UK governments in conjunction with the NHS in each of the countries. We’re not therefore in a position to take specific action to secure numbers of doctor in this speciality, or in any others.” Source location Response from General Medical Council
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 Recruitment and retention of doctors are exclusively matters for the NHS in each UK country, outside the regulator’s direct role.
Verbatim wording from the response “The GMC, as the statutory regulator for the medical profession, does not have a direct role in the recruitment or retention of doctors across any specialty in the UK. This is exclusively a matter for the NHS in each of the four UK countries. Similarly, although we have responsibility for the oversight of postgraduate medical training, we have no role in determining how many doctors are trained in any specialty or subspecialty. These numbers are set by each of the UK governments in conjunction with the NHS in each of the countries. We’re not therefore in a position to take specific action to secure numbers of doctor in this speciality, or in any others.” Source location Response from General Medical Council
Open published response
6 Jun 2023 Alexander Shone BLEWITT · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 7 Failure to correct and monitor prescribing clinicians' failure to sign off IV fluid prescriptions View source Lack of effective, reliable recording of intravenous fluids administered in the emergency department View source Failure to accurately transcribe communications received at emergency department triage View source Failure to bring issues of concern to the attention of hospital authorities View source Failure of attending doctors to review source communications themselves View source Failure of incident investigations to provide detailed, evidence-challenging analysis View source Failure of treating doctors to make accurate clinical notes of major presenting symptoms View source See 4 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
Alexander Shone BLEWITT · 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
Alexander Shone Blewitt died at Milton Keynes University Hospital on 11 July 2022 after returning to the emergency department with faecal incontinence and abdominal pain, following an earlier visit where he had been referred from an urgent care centre. A possible acute abdomen was confirmed by CT, and he suffered a cardiac arrest before surgery. Concerns included inaccurate communication of important symptoms and treatment information, inadequate clinical recording, and the absence of reliable records of intravenous fluids administered in the emergency department.
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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to correct and monitor prescribing clinicians' failure to sign off IV fluid prescriptions
Wider context from the report “[5] The Incident Investigation Report which is in part designed to assist with learning from adverse events was of a generally poor standard. There was a failure to consider issues in detail; there was a failure to challenge the statements of clinicians where there were obvious contradictions between statements made and the medical record; there was a failure to put in place measures to correct and monitor prescribing clinicians failure to sign off on IV fluid prescriptions so that the contemporaneous record would be available for clinicians coming after them and they could see whether a patient had satisfactory or unsatisfactory fluid management . The only record in the case was a typed note by a junior doctor to the effect that it was thought Mr Blewitt had received 2 litres of fluid since arrival.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of effective, reliable recording of intravenous fluids administered in the emergency department
Wider context from the report “[1] At the time of Mr Blewitt's death there was no effective, reliable recording of intravenous fluids administered to patients in the emergency department . That in my view has potential to represent a threat to the safety and lives of patients suffering with a wide variety of different conditions. The author of the SI report who attended to give evidence did not, at the time of request 8 months later, was unable to demonstrate that the Trust had remedied that.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately transcribe communications received at emergency department triage
Wider context from the report “[3] On arrival at the ED a triage nurse summarised the communication from the urgent care centre. The triage nurse missed important points during the transcription . The attending doctor did not concern himself to look at the communication himself.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to bring issues of concern to the attention of hospital authorities
Wider context from the report “[2] Despite the 8 month interval between Mr Blewitt's death and the Inquest the issues of concern had not been brought to the attention of hospital authorities .
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure of attending doctors to review source communications themselves
Wider context from the report “[3] On arrival at the ED a triage nurse summarised the communication from the urgent care centre. The triage nurse missed important points during the transcription. The attending doctor did not concern himself to look at the communication himself .
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure of incident investigations to provide detailed, evidence-challenging analysis
Wider context from the report “[5] The Incident Investigation Report which is in part designed to assist with learning from adverse events was of a generally poor standard . There was a failure to consider issues in detail ; there was a failure to challenge the statements of clinicians where there were obvious contradictions between statements made and the medical record ; there was a failure to put in place measures to correct and monitor prescribing clinicians failure to sign off on IV fluid prescriptions so that the contemporaneous record would be available for clinicians coming after them and they could see whether a patient had satisfactory or unsatisfactory fluid management. The only record in the case was a typed note by a junior doctor to the effect that it was thought Mr Blewitt had received 2 litres of fluid since arrival.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure of treating doctors to make accurate clinical notes of major presenting symptoms
Wider context from the report “[4] I was concerned that the treating doctor made aaneous note on the 9th July 2022 at Mr Blewitt's first presentation which failed to record the major presenting symptom, diarrhoea with faecal incontinence , which Mr Blewitt had communicated to the urgent care doctor who in turn had included that in her notes and letter to the ED. The treating doctor did record a flatly contradictory note to the effect there was no change in bowel habit .
” Open source report
29 Mar 2023 Angela Jean Kearn · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Failure to provide sufficiently prominent warnings about full-face mask risks to affected users View source Lack of medical-profession awareness and training on Immersion Pulmonary Oedema View source Failure of mask safety testing to replicate general-public use conditions View source Lack of applicable standards for full-face snorkelling masks View source See 1 more concern
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
Angela Jean Kearn · 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
Angela Jean Kearn, aged 63, collapsed and died while snorkelling in Egypt on 13 January 2020. The inquest identified immersion pulmonary oedema as the cause of death, with hypertension, hormone replacement therapy and use of a full-face snorkel mask each contributing more than minimally. Concerns included limited medical awareness of immersion pulmonary oedema and insufficiently publicised safety warnings about using full-face snorkel masks with cardiovascular or respiratory conditions.
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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficiently prominent warnings about full-face mask risks to affected users
Wider context from the report “ix.) Decathlon have recently updated their website in the United Kingdom to include the following, “It is not recommended to use this product if you have any ongoing respiratory or cardiovascular issues including but not limited to chest infection, asthma, high/raised blood pressure (hypertension), heart disease or angina etc. If you have any doubts or questions relating to this please check with your medical practitioner.” The same additional wording is being translated and added to all websites of the company.
x.) The packaging of the mask has been revised to show a pictogram to warn against use of the mask by those with heart or other cardiovascular conditions.
xi.) The concern is that many million of the full face masks have been sold and the safety concerns about their use by those with ongoing cardiovascular and respiratory issues has not been widely publicised or brought to the attention of those who already own the masks . Those purchased before 2017 had no warning in relation to these matters and the warning included in the instructions from 2017 inwards was not prominent nor sufficient to alert prospective purchasers to the hazards of use which have now been identified .
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of medical-profession awareness and training on Immersion Pulmonary Oedema
Wider context from the report “Awareness of Immersion Pulmonary Oedema in the medical profession:
i.) Concerns were raised by the medical witnesses that there is very little awareness of Immersion Pulmonary Oedema in the medical profession and that it is not addressed in medical training , as a consequence, it can be missed by those treating the condition and is often mistaken for drowning.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure of mask safety testing to replicate general-public use conditions
Wider context from the report “The Full Face Mask
ii.) At the time that the Easybreath full face snorkel mask was developed by Decathlon there were no United Kingdom or European Standards which were applicable to a full face snorkelling mask.
iii.) In the course of its development, Decathlon commissioned a number of tests to be undertaken on it, but it was accepted in evidence that the tests undertaken did not replicate the conditions of the use of the mask by the general public .
iv.) Decathlon have sold over 16 million of the masks. Other such masks are also on the market.
v.) The Decathlon usage instructions for the full face mask, contained in small print, have been amended over time. From the 17th August 2015 the instructions included a warning that you must make sure that you are in good physical condition before snorkelling and that the mask is not suitable for swimming.
vi.) Further tests were undertaken and an Ergomedical report considered the issue of whether use of the mask and inhalation through the mask’s dead space gave rise to excess carbon dioxide inhalation. The report concluded “we strongly recommend to advise against wearing Easybreath masks to people who suffer from underlying cardio-respiratory conditions.”
vii.) As a result, Decathlon amended their instructions for use to include that the mask should not be used if the user has unstable cardio-respiratory pathologies, that the mask is to be used under conditions of submaximal exercise (mild to moderate) and that it is not suitable for active swimming.
viii.) Development of a United Kingdom standard in relation to this type of mask is now being put in train but has not yet begun and is likely to take some time.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of applicable standards for full-face snorkelling masks
Wider context from the report “The Full Face Mask
ii.) At the time that the Easybreath full face snorkel mask was developed by Decathlon there were no United Kingdom or European Standards which were applicable to a full face snorkelling mask .
iii.) In the course of its development, Decathlon commissioned a number of tests to be undertaken on it, but it was accepted in evidence that the tests undertaken did not replicate the conditions of the use of the mask by the general public.
iv.) Decathlon have sold over 16 million of the masks. Other such masks are also on the market.
v.) The Decathlon usage instructions for the full face mask, contained in small print, have been amended over time. From the 17th August 2015 the instructions included a warning that you must make sure that you are in good physical condition before snorkelling and that the mask is not suitable for swimming.
vi.) Further tests were undertaken and an Ergomedical report considered the issue of whether use of the mask and inhalation through the mask’s dead space gave rise to excess carbon dioxide inhalation. The report concluded “we strongly recommend to advise against wearing Easybreath masks to people who suffer from underlying cardio-respiratory conditions.”
vii.) As a result, Decathlon amended their instructions for use to include that the mask should not be used if the user has unstable cardio-respiratory pathologies, that the mask is to be used under conditions of submaximal exercise (mild to moderate) and that it is not suitable for active swimming.
viii.) Development of a United Kingdom standard in relation to this type of mask is now being put in train but has not yet begun and is likely to take some time .
” Open source report
18 May 2022 Matthew John Evans · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 12 Failure to ensure review of correspondence from TalkPlus View source Lack of guidance on thresholds for referral to secondary mental health services View source Failure to undertake mental health assessment and identify need for further or secondary mental health support View source Failure to document warnings about Mirtazepine side-effects and increased suicidal ideation risk View source Failure to confirm electronic letters are read and acted upon View source Prescribing of Mirtazepine without sufficient mental health prescribing competence View source Lack of ongoing mental health training for GPs View source Failure to offer face-to-face consultation or arrange follow-up View source Failure to ask about or document suicidal ideation and self-harm View source Failure to investigate and review deaths for learning and implementation of necessary changes View source Lack of prescribing policy for Mirtazapine, antidepressants and anxiolytics View source Failure to seek permission to involve partners and family in ongoing care View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Matthew John Evans · 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 John Evans was a 47-year-old man who developed insomnia, anxiety and depression during the third COVID-19 lockdown and died on 16 June 2021 after ending his life. The principal concerns related to the GP’s lack of mental-health assessment, suicide-risk assessment, follow-up and consideration of referral; the general practice’s prescribing, communication and clinical-governance arrangements; and TalkPlus’s lack of clear guidance on referral to secondary mental-health services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure review of correspondence from TalkPlus
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on thresholds for referral to secondary mental health services
Wider context from the report “3. The actions of TalkPlus
There does not appear to be robust guidance or a policy as to the threshold necessary to refer a patient to secondary mental health services in Matthew’s circumstances where his mental health had deteriorated as the sessions progressed and he had began to indicate suicidal ideation and self-harm on a background of no previous mental health difficulties.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake mental health assessment and identify need for further or secondary mental health support
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to document warnings about Mirtazepine side-effects and increased suicidal ideation risk
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm electronic letters are read and acted upon
Wider context from the report “2. The actions of the General Practice
No policy was provided to assist GP’s with prescribing of Mirtazapine and antidepressants and anxiolytics in general practice. There is no confirmation electronic letters have been signed as read and acted upon by the relevant GP. No evidence was provided with regard to ongoing training in mental health for GP’s. Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the practice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Prescribing of Mirtazepine without sufficient mental health prescribing competence
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of ongoing mental health training for GPs
Wider context from the report “2. The actions of the General Practice
No policy was provided to assist GP’s with prescribing of Mirtazapine and antidepressants and anxiolytics in general practice. There is no confirmation electronic letters have been signed as read and acted upon by the relevant GP. No evidence was provided with regard to ongoing training in mental health for GP’s. Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the practice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to offer face-to-face consultation or arrange follow-up
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ask about or document suicidal ideation and self-harm
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate and review deaths for learning and implementation of necessary changes
Wider context from the report “2. The actions of the General Practice
No policy was provided to assist GP’s with prescribing of Mirtazapine and antidepressants and anxiolytics in general practice. There is no confirmation electronic letters have been signed as read and acted upon by the relevant GP. No evidence was provided with regard to ongoing training in mental health for GP’s. Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the practice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of prescribing policy for Mirtazapine, antidepressants and anxiolytics
Wider context from the report “2. The actions of the General Practice
No policy was provided to assist GP’s with prescribing of Mirtazapine and antidepressants and anxiolytics in general practice. There is no confirmation electronic letters have been signed as read and acted upon by the relevant GP. No evidence was provided with regard to ongoing training in mental health for GP’s. Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the practice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to seek permission to involve partners and family in ongoing care
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No further investigation is considered necessary, although the concerns will be shared for discussion during revalidation.
Verbatim wording from the response “The AR is assured that the matters contained in your complaint do not raise concerns that ████████ poses either a risk to patients or undermines the public’s confidence in doctors. Although we do not need to investigate further, we will share your concerns with the doctor’s responsible officer and ask the doctor to discuss it with their appraiser as part of their revalidation.” Source location Response from General Medical Council(2)
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The concerns do not indicate that the doctor poses a patient risk or undermines public confidence in doctors.
Verbatim wording from the response “The AR is assured that the matters contained in your complaint do not raise concerns that ████████ poses either a risk to patients or undermines the public’s confidence in doctors. Although we do not need to investigate further, we will share your concerns with the doctor’s responsible officer and ask the doctor to discuss it with their appraiser as part of their revalidation.” Source location Response from General Medical Council(2)
Open published response
16 Mar 2022 Billy Longshaw · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Flawed and limited review of serious clinical incidents View source Failure to undertake detailed, rigorous and effective investigations of serious clinical incidents View source Insufficient doctors’ familiarity with the practical application of the Mental Capacity Act 2005 View source Inadequate education on the Mental Capacity Act 2005 for medical students View source See 1 more concern
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
Billy Longshaw · 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
Billy Longshaw died at Stepping Hill Hospital on 7 March 2021 from complications of an undiagnosed sigmoid volvulus, following an earlier Emergency Department assessment at Great Western Hospital. He was allowed to leave without basic blood tests, a diagnosis, or serious abdominal pathology being fully excluded. Concerns included the lack of a detailed investigation by the Trust, flaws in its incident review, and the adequacy of education and practical understanding concerning the Mental Capacity Act 2005.
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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Flawed and limited review of serious clinical incidents
Wider context from the report “2) The ’48 Hour Report for Significant incidents resulting in Moderate Harm and above’ prepared by an ED Consultant and others is fundamentally and obviously flawed (even when read against the Trust’s own medical records), prefaced as it is by the assumption that ‘the patient self-discharged against medical advice’ . The Trust’s (limited) review of this matter represents a missed opportunity to consider vital issues such as the presentation of patients with significant learning disabilities to the Emergency Department, and the practical application of the Mental Capacity Act 2005 in this clinical setting .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake detailed, rigorous and effective investigations of serious clinical incidents
Wider context from the report “1) Notwithstanding Mr Longshaw died within 24 hours of being seen in the Emergency Department at Great Western Hospitals, Swindon, in circumstances where he was permitted to leave without basic blood tests being taken, any diagnosis being made, or serious abdominal pathology being fully excluded, it is a matter of concern that the Trust has not undertaken a detailed investigation into the care and treatment provided to him .
Prompt, rigorous and effective investigations into serious clinical incidents are essential to deriving learning and improving patient safety ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient doctors’ familiarity with the practical application of the Mental Capacity Act 2005
Wider context from the report “3) Mr Longshaw’s death raises issues as to the adequacy of education provided to medical students as to the Mental Capacity Act 2005, and doctors’ of all levels familiarity with the practical application of this legislation in clinical settings , and accompanying guidance such as that produced by the General Medical Council in this regard .
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate education on the Mental Capacity Act 2005 for medical students
Wider context from the report “3) Mr Longshaw’s death raises issues as to the adequacy of education provided to medical students as to the Mental Capacity Act 2005 , and doctors’ of all levels familiarity with the practical application of this legislation in clinical settings, and accompanying guidance such as that produced by the General Medical Council in this regard.
” Open source report
Concerns raised 8 Failure to protect questionnaire answers from alteration View source Failure to flag refusal to share prescribing information for further enquiry View source Lack of central tracking of prescribed and dispensed drugs View source Lack of required face-to-face consultation before dispensing drugs View source Inadequate questionnaire on the person's medical history View source Failure to notify the person's GP of prescribed drugs View source Limited regulation of the prescribing company View source Failure to prevent drug selection before prescriber contact View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jamie Francis O'Connor · 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
Jamie O’Connor was found deceased in the garden of his home in Leicester on 14 October 2018 after his mother became concerned that he was not responding to phone calls. The report identified concerns about online prescribing, including the lack of central tracking, limited information sharing with GPs, no required face-to-face consultation, limited questionnaires, patients requesting specific drugs, and limited regulation; the inquest concluded that this was a drug-related death and recorded the cause as ████████ toxicity.
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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to protect questionnaire answers from alteration
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed ;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to flag refusal to share prescribing information for further enquiry
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of central tracking of prescribed and dispensed drugs
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of required face-to-face consultation before dispensing drugs
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed ;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate questionnaire on the person's medical history
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the person's GP of prescribed drugs
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Limited regulation of the prescribing company
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent drug selection before prescriber contact
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber ;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch a call for evidence on remote consultations and prescribing to assess whether existing guidance remained appropriate for changing practice and technology.
Verbatim wording from the response “I appreciate that the events giving rise to this inquest date from several years ago. In late 2019 we launched a call for evidence in relation to remote consultations and prescribing. This explored whether our existing guidance, which was last updated in 2013 and which applied at the time of Mr O’Connor’s death, had kept pace with changes in practice and the use of technology.” Source location 2021-0363-Response-from-GMC_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish updated prescribing guidance covering remote consultation suitability, information sharing, patient dialogue, and safeguards for controlled or potentially addictive medicines.
Verbatim wording from the response “Following this exercise, we published updated guidance for doctors on prescribing in February 2021. This now places a greater emphasis on following the principles of good practice regardless of the medium through which a consultation is taking place, face to face or online.” Source location 2021-0363-Response-from-GMC_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Systems for accessing and sharing prescribing and dispensing information are outside the respondent’s remit.
Verbatim wording from the response “Systems for accessing and sharing information about the prescribing and dispensing of medicines are outside the GMC’s remit. However, we strongly agree that effective systems are vital to ensuring safe and effective care.” Source location 2021-0363-Response-from-GMC_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department of Health and Social Care and Care Quality Commission are better placed to address regulation of health service organisations in England.
Verbatim wording from the response “The GMC’s remit does not extend to organisations that provide health services. The Department of Health and Social Care and the Care Quality Commission may be better placed to comment on this issue as far as it relates to England.” Source location 2021-0363-Response-from-GMC_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Regulation of organisations providing health services is outside the respondent’s remit.
Verbatim wording from the response “The GMC’s remit does not extend to organisations that provide health services. The Department of Health and Social Care and the Care Quality Commission may be better placed to comment on this issue as far as it relates to England.” Source location 2021-0363-Response-from-GMC_Published
Open published response
10 Sep 2021 Billy Martyn WARWICK-JONES · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Absence of specific driving guidance for sudden-onset confusion or delirium in physically unwell older people View source Failure to advise drivers and families that confusion, agitation or delirium may render driving unfit View source Insufficient road-safety instruction for older drivers View source Insufficient road-safety testing of older drivers View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Billy Martyn WARWICK-JONES · 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
Billy was killed while riding his motorbike when he was struck head-on by a car travelling on the wrong side of the A3. The driver was elderly, unwell with a urinary tract infection, delirious and had driven for 16 hours. The concerns included insufficient advice about delirium-related unfitness to drive and inadequate testing and guidance on road safety for older drivers.
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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Absence of specific driving guidance for sudden-onset confusion or delirium in physically unwell older people
Wider context from the report “The driver of the vehicle that caused this death was unwell with a urine tract infection. He had previously been treated for a urine tract infection. There is no evidence to suggest that he or his family were advised that he may demonstrate symptoms of confusion, agitation or delirium as a consequence of this and they would render him unfit to drive.
There appears to be insufficient testing and instruction of the older population with regards to road safety, which led to this tragic outcome. While there are guidelines for driving for dementia or mild cognitive impairment produced by the General Medical Council, there appears to be nothing specific to other sudden onset confusion or delirium which is a well recognised and common symptom in the elderly when physically unwell.
It is recognised that our population are growing older and that an increasing number of this cohort will have a driving licence. It is of concern that a situation can arise that leads to the loss of another drivers life, and additional lives could very easily have been lost as a consequence of this incident. Consideration should be given to more frequent, rigorous testing and to consider the duties that should be placed on the driver, their medical practitioners and also family members/carers to report changes in presentation or health to the Driver and Vehicle Licensing Agency.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to advise drivers and families that confusion, agitation or delirium may render driving unfit
Wider context from the report “The driver of the vehicle that caused this death was unwell with a urine tract infection. He had previously been treated for a urine tract infection. There is no evidence to suggest that he or his family were advised that he may demonstrate symptoms of confusion, agitation or delirium as a consequence of this and they would render him unfit to drive.
There appears to be insufficient testing and instruction of the older population with regards to road safety, which led to this tragic outcome. While there are guidelines for driving for dementia or mild cognitive impairment produced by the General Medical Council, there appears to be nothing specific to other sudden onset confusion or delirium which is a well recognised and common symptom in the elderly when physically unwell.
It is recognised that our population are growing older and that an increasing number of this cohort will have a driving licence. It is of concern that a situation can arise that leads to the loss of another drivers life, and additional lives could very easily have been lost as a consequence of this incident. Consideration should be given to more frequent, rigorous testing and to consider the duties that should be placed on the driver, their medical practitioners and also family members/carers to report changes in presentation or health to the Driver and Vehicle Licensing Agency.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient road-safety instruction for older drivers
Wider context from the report “The driver of the vehicle that caused this death was unwell with a urine tract infection. He had previously been treated for a urine tract infection. There is no evidence to suggest that he or his family were advised that he may demonstrate symptoms of confusion, agitation or delirium as a consequence of this and they would render him unfit to drive.
There appears to be insufficient testing and instruction of the older population with regards to road safety , which led to this tragic outcome. While there are guidelines for driving for dementia or mild cognitive impairment produced by the General Medical Council, there appears to be nothing specific to other sudden onset confusion or delirium which is a well recognised and common symptom in the elderly when physically unwell.
It is recognised that our population are growing older and that an increasing number of this cohort will have a driving licence. It is of concern that a situation can arise that leads to the loss of another drivers life, and additional lives could very easily have been lost as a consequence of this incident. Consideration should be given to more frequent, rigorous testing and to consider the duties that should be placed on the driver, their medical practitioners and also family members/carers to report changes in presentation or health to the Driver and Vehicle Licensing Agency.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient road-safety testing of older drivers
Wider context from the report “The driver of the vehicle that caused this death was unwell with a urine tract infection. He had previously been treated for a urine tract infection. There is no evidence to suggest that he or his family were advised that he may demonstrate symptoms of confusion, agitation or delirium as a consequence of this and they would render him unfit to drive.
There appears to be insufficient testing and instruction of the older population with regards to road safety, which led to this tragic outcome. While there are guidelines for driving for dementia or mild cognitive impairment produced by the General Medical Council, there appears to be nothing specific to other sudden onset confusion or delirium which is a well recognised and common symptom in the elderly when physically unwell.
It is recognised that our population are growing older and that an increasing number of this cohort will have a driving licence. It is of concern that a situation can arise that leads to the loss of another drivers life, and additional lives could very easily have been lost as a consequence of this incident. Consideration should be given to more frequent, rigorous testing and to consider the duties that should be placed on the driver, their medical practitioners and also family members/carers to report changes in presentation or health to the Driver and Vehicle Licensing Agency.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Setting clinical standards and providing clinical guidance on specific driving conditions falls outside the respondent’s role.
Verbatim wording from the response “We do not specify particular conditions that might affect a patient’s fitness to drive or give guidelines for driving with particular conditions as we do not set clinical standards or provide clinical guidance. This is the role of a wide range of other bodies. However, we outline to doctors that when assessing a patient’s condition and providing treatment, they should refer to the DVLA’s guidance Assessing fitness to drive- a guide for medical professionals, which includes more detailed information about specific disorders and conditions that can impair a patient’s fitness to drive.” Source location Response from GMC
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The DVLA and DVA are legally responsible for deciding whether a person is medically unfit to drive.
Verbatim wording from the response “The Driver and Vehicle Licensing Agency (DVLA) in England, Scotland and Wales and the Driver and Vehicle Agency (DVA) in Northern Ireland are legally responsible for deciding if a person is medically unfit to drive, and we say that if a doctor is unsure whether the patient’s condition would affect their ability to drive safely, they should seek advice from an experienced colleague or the DVLA or DVA’s medical adviser.” Source location Response from GMC
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Particular conditions and a general duty for increased testing cannot be specified because fitness to drive requires case-by-case assessment and DVLA or DVA involvement.
Verbatim wording from the response “For the reasons outlined above, we are unable to specify particular conditions in our guidance including a general duty for increased testing, as each patient would need to be considered by their doctor on a case by case basis before being assessed by the DVLA.” Source location Response from GMC
Open published response
20 Apr 2021 Ella Adoo-Kissi-Debrah · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Insufficient undergraduate teaching on the health effects of air pollution View source Insufficient postgraduate education on the health effects of air pollution View source Insufficient detail and monitoring capacity for air quality information View source Insufficient professional guidance on communicating the health effects of air pollution View source Low public awareness of sources of national and local pollution information View source National Particulate Matter limits exceeding WHO guideline levels View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ella Adoo-Kissi-Debrah · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ella Adoo-Kissi-Debrah died aged 9 after an asthmatic episode led to cardiac arrest on 15 February 2013. The report states that air pollution, including exposure to nitrogen dioxide and particulate matter from traffic emissions, significantly contributed to her asthma and death. It also identifies concerns about pollution limits, public access to pollution information, and communication of air-pollution health risks by healthcare professionals.
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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient undergraduate teaching on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient postgraduate education on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail and monitoring capacity for air quality information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government. The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors .
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient professional guidance on communicating the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Low public awareness of sources of national and local pollution information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government . The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation National Particulate Matter limits exceeding WHO guideline levels
Wider context from the report “(1) The national limits for Particulate Matter are set at a level far higher than the WHO guidelines. The evidence at the inquest was that there is no safe level for Particulate Matter and that the WHO guidelines should be seen as minimum requirements. Legally binding targets based on WHO guidelines would reduce the number of deaths from air pollution in the UK.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the Medical Licensing Assessment with social and population health content and relevant practical procedures.
Verbatim wording from the response “Introduction of Medical Licensing Assessment” Source location 2021-0113-Response-from-General-Medical-Council-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore with the Academy of Medical Royal Colleges whether environmental impacts, social inequality and health promotion should form transferable postgraduate learning content.
Verbatim wording from the response “We will explore with the AoMRC whether the themes raised (environmental impacts/social inequality/health promotion) could be areas where key transferable content, knowledge and skills could be shared across postgraduate specialities.” Source location 2021-0113-Response-from-General-Medical-Council-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update Outcomes for graduates to include environmental exposure, environmental health factors and mitigation of related hazards.
Verbatim wording from the response “We determine and publish the high-level outcomes all medical students are required to demonstrate in order to graduate. We updated our Outcomes for graduates in 2018 after extensive consultation. This is supplemented by a set of core Practical skills and procedures graduates must have achieved when they start work for the first time so they can practise safely. The content map which underpins the forthcoming Medical Licensing Assessment (explained in more detail later) is based on these outcomes and practical procedures.” Source location 2021-0113-Response-from-General-Medical-Council-Redacted
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 Publish the Generic professional capabilities framework requiring doctors in training to address health inequalities and health promotion.
Verbatim wording from the response “The curricula for postgraduate specialty training are set by individual medical royal colleges and faculties. In 2017 we published revised standards for curricula - Excellence by design - which requires curricula to be mapped against our Generic professional capabilities framework of shared generic and specialty-specific outcomes. The framework sets the essential capabilities which underpin professional medical practice and are a fundamental part of all postgraduate training programmes. The capabilities include a section on understanding health inequalities and health promotion, which is required of all doctors in training. Most royal colleges and faculties have now reviewed their specialty curricula against our revised standards.” Source location 2021-0113-Response-from-General-Medical-Council-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The regulator’s powers do not extend to mandating specific content in undergraduate medical curricula.
Verbatim wording from the response “Our powers don’t extend to mandating specific content in undergraduate curricula, but the outcomes do describe relevant key themes around the environmental factors contributing to health. These include requiring newly qualified doctors to:” Source location 2021-0113-Response-from-General-Medical-Council-Redacted
Open published response
31 Mar 2021 Joan Mavis COLEY · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 6 Lack of doctors' understanding of taking bloods from central lines and associated risks View source Failure to formally assess junior doctors' competence to take bloods from central lines View source Failure to formally assess and monitor doctors' procedural competence View source Limited medical school training on taking bloods from central lines and associated risks View source Failure to hand over junior doctors' procedural competencies between wards View source Lack of a standard written procedure for taking bloods from central lines 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.
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AI-generated summary
Joan Mavis COLEY · 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
Joan Mavis COLEY, who had end stage renal failure requiring dialysis, diabetes and an infected right foot, suffered a cardiac arrest after air entered her central dialysis line while blood was being taken. She was resuscitated but subsequently developed sepsis and died on 27 November 2020. The principal concerns were inadequate training, supervision, competency assessment and handover for junior doctors taking blood from central lines, together with the absence of a clear standard operating procedure.
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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of doctors' understanding of taking bloods from central lines and associated risks
Wider context from the report “5. General understanding of the process to follow when taking blood from a central line and the associated risks: The inquest heard how there was a general lack of understanding of how to take bloods from a central line and the associated risks . The basic physiology was not understood and the consultant also did not know how to take blood from this central line . Consideration should be given to ensuring all doctors are fully aware of the basic principles when taking bloods from a central line and the associated risks.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to formally assess junior doctors' competence to take bloods from central lines
Wider context from the report “2. Induction programme for FY1 Doctors and assessment of base line competencies: The inquest heard how taking bloods from a central line is not part of the "check list" of tasks that junior doctors have to undertake . As a result there was no process in place to check whether an individual doctor was competent take bloods from a central line . This is inherently unsafe. Consideration should be given to adding "taking bloods from a central line" to the checklist of tasks.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to formally assess and monitor doctors' procedural competence
Wider context from the report “3. How to effectively assess and monitor competencies to undertake procedures: The inquest heard how there was no formal system for assessing a doctor's competence to undertake a particular task for example, taking bloods from a central line. The doctor would learn on the job with no formal training or assessment . When moving wards if a doctor agreed to undertake a procedure it was assumed they were competent and competent . This is inherently unsafe. The inquest heard how nurses have stringent criteria and training before they can handle any procedures. Consideration should be given to a similar process for junior doctors.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Limited medical school training on taking bloods from central lines and associated risks
Wider context from the report “1. Medical school training: The inquest heard evidence that there is very limited training on how to take bloods from a central line, the physiology involved and potential risks . The junior doctor in question did not feel she had adequate knowledge of the potential risk associated with the task she was undertaking. Urgent action is required to review what training is provided to medical students regarding taking bloods from central lines.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to hand over junior doctors' procedural competencies between wards
Wider context from the report “4. Handover of competencies from ward to ward: The inquest heard how there was no system of hand over when junior doctors change from ward to ward . The junior doctor in this case was shadowing on a new ward and the Consultant in charge had no understanding of the doctors level of ability or competency . Consideration should be given to having a system to hand over ability and competencies.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a standard written procedure for taking bloods from central lines
Wider context from the report “6. Standard operating procedures for taking bloods from central lines: The inquest heard how there was no standard written procedure for taking bloods from a central line . Consideration should be given to having a national standard procedure, which should be linked with training and assessment of competency for doctors to take bloods from a central line.
” Open source report
Concerns raised 7 Unavailability of consultant-level psychiatric input to eating disorder services View source Inadequate training and knowledge of eating disorders among medical professionals View source Under-reporting and inadequate recording and investigation of eating-disorder-related deaths View source Lack of robust and reliable prevalence data for eating disorders View source Shortage of eating disorder specialists View source Lack of formally commissioned monitoring provision for moderate to high risk Anorexia Nervosa patients View source COVID-19 pandemic exacerbation of eating disorder safety deficiencies View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Averil Hart · 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
Averil Hart died from anorexia nervosa on 15 December 2012, after severe weight loss and deterioration following her discharge from specialist eating-disorder treatment. The report identified concerns about inadequate monitoring and coordination of care, insufficient eating-disorder training and specialist provision, failures to provide nutritional support, delays and miscommunication in hospital care, inadequate data on eating-disorder prevalence and deaths, and the impact of the COVID-19 pandemic.
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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of consultant-level psychiatric input to eating disorder services
Wider context from the report “(2) Lack of formally commissioned service level agreement for the provision of robust and effective monitoring of moderate to high risk AN patients by primary or secondary care providers
Evidence confirmed that in response to the PHSO Report an Expert Reference Group (ERG) was convened by NHS England (NHSE) to address the specific recommendation for NHSE to review the existing quality and availability of services to achieve parity for adult ED services with children and young people’s ED services. The National Collaborating Centre for Mental Health (NCCMH) was commissioned to develop new guidance published in August 2019: “Adult Eating Disorders: Community, Inpatient and Intensive Day Patient Care – Guidance for Commissioners and Providers”.
However, the clear and unchallenged evidence received at Averil’s inquest confirmed that there remains a lack of formally commissioned provision for the monitoring of AN patients in primary or secondary care across large parts of the United Kingdom. Whilst the evidence received indicated that Cambridgeshire & Peterborough NHS Foundation Trust are seeking to develop models to ensure the provision of medical monitoring for all ED sufferers, including moderate to high risk patients, there are many areas in the country – including parts of the East of England Region – which still have no such formally commissioned provision. Further, unchallenged evidence identified a number of regions as not even having consultant level psychiatric in-put to the ED services that are purportedly available .
There was unanimity on the part of each of the senior clinicians who gave evidence, as well as a number of independent, instructed experts in the fields of ED and AN, that the continued absence of such monitoring and treatment provision gave rise to not only the risk of avoidable future deaths, but - in the views of many - the inevitability of the same. Evidence confirmed that whilst AN has the highest mortality of any mental disorder affecting young people and adults this should not be simply accepted and that AN and other EDs are treatable mental disorders, with even severe complications such as malnutrition safely reversible. The evidence further established that whilst in the long term primary prevention strategies including early recognition and treatment of the disease was critical, in the short to medium term, improving access to treatment and the effective monitoring of the severely ill is to be regarded as essential to address the risk of avoidable future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate training and knowledge of eating disorders among medical professionals
Wider context from the report “(1) Inadequate training of doctors and other medical professionals re eating disorders
Evidence from a wide range of clinicians who had engaged with Averil in 2012 echoed the evidence of clinicians attending the four inquests of the women referred to above. All five inquests revealed a common theme of wide-spread and continuing lack of training, knowledge, or experience on the part of physicians and medical staff (including GPs and nurse practitioners, as well as acute hospital doctors, nurses and dieticians) regarding eating disorders (EDs) and specifically Anorexia Nervosa (AN). Many witnesses (from both the death 2012 and those in 2017/2018) conceded that they had only the most superficial knowledge of the often complex issues relating to recognition, monitoring, management and treatment of EDs and AN specifically. Their evidence often reflected a lack of familiarity with the King’s College Guidance for the treatment of AN in the community. The evidence of hospital staff revealed, at best, inconsistent implementation of the Royal College of Psychiatrists MARSIPAN guidance for the emergency treatment of AN patients and, at worst, a failure to implement the Guidance at all .
Evidence at Averil’s inquest (and at those of ████████) suggested that limited progress has been made in respect of the PHSO recommendation with regard to the training of doctors and other medical professionals, (notwithstanding the further recommendations of the PACAC Follow-up Report and the Government Response to the latter’s Recommendations). These concerns have been reiterated by the Position Statement of the Royal College of Psychiatrists (PS04/20) of September 2020 “Improving core skills and competence in risk assessment and management of people with eating disorders: What all doctors need to know.”
The evidence at inquest of senior practitioners in the fields of psychiatry, psychology, acute medicine, dietetics, gastroenterology and GP practice all confirmed that there remains, as there was in 2012, a continuing and serious shortage of eating disorder specialists across the country with many Trusts finding it difficult to fill vacancies; such shortages inevitably impact upon the level and quality of support available to primary care providers and other specialists and therefore, in my view, risks avoidable future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Under-reporting and inadequate recording and investigation of eating-disorder-related deaths
Wider context from the report “(3) Lack of robust and reliable data regarding the prevalence of eating disorders
Evidence also confirmed that the lack of precise information on the prevalence of eating disorders in the United Kingdom, described by the PHSO Report and the PACAC Follow-up Report as “shocking, given the claim that up to 1.25 million people are suffering from an eating disorder and the fact that eating disorders have the highest mortality rate of mental illnesses” persists. The witness evidence also confirmed the view expressed in the PACAC Report. “This vagueness limits the ability of NHS commissioners to gauge what services need to be provided and encourages them to devote resources to better recorded diseases.”
Further, I am concerned that there may also be a significant under-reporting of the extent to which EDs have caused or contributed to deaths , leading to cases either not being referred to the coroner or, if they are, the coroner in question determining that death was one of ‘natural causes’, with only the terminal cause of death, and not the underlying ED cause or contribution to the death, being recorded . In such circumstances there is a concern that a number of such deaths (where, for example, lack of care may have contributed to the death) are neither investigated appropriately by the coroner nor taken to inquest with a concomitant risk of a significant under-estimation of the true mortality rate of EDs.
(I propose to explore this issue in separate correspondence with the Medical Examiner for England and Wales (copied in to this Report), the Office for National Statistics and the Coroners’ Society of England and Wales).
In my view, taken together, the absence of statistically robust data on the numbers of those suffering from EDs and the potential under-estimation of those deaths to which EDs may have caused or contributed, gives rise to an objective risk that avoidable ED deaths will continue in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of robust and reliable prevalence data for eating disorders
Wider context from the report “(3) Lack of robust and reliable data regarding the prevalence of eating disorders
Evidence also confirmed that the lack of precise information on the prevalence of eating disorders in the United Kingdom , described by the PHSO Report and the PACAC Follow-up Report as “shocking, given the claim that up to 1.25 million people are suffering from an eating disorder and the fact that eating disorders have the highest mortality rate of mental illnesses” persists. The witness evidence also confirmed the view expressed in the PACAC Report. “This vagueness limits the ability of NHS commissioners to gauge what services need to be provided and encourages them to devote resources to better recorded diseases.”
Further, I am concerned that there may also be a significant under-reporting of the extent to which EDs have caused or contributed to deaths, leading to cases either not being referred to the coroner or, if they are, the coroner in question determining that death was one of ‘natural causes’, with only the terminal cause of death, and not the underlying ED cause or contribution to the death, being recorded. In such circumstances there is a concern that a number of such deaths (where, for example, lack of care may have contributed to the death) are neither investigated appropriately by the coroner nor taken to inquest with a concomitant risk of a significant under-estimation of the true mortality rate of EDs.
(I propose to explore this issue in separate correspondence with the Medical Examiner for England and Wales (copied in to this Report), the Office for National Statistics and the Coroners’ Society of England and Wales).
In my view, taken together, the absence of statistically robust data on the numbers of those suffering from EDs and the potential under-estimation of those deaths to which EDs may have caused or contributed, gives rise to an objective risk that avoidable ED deaths will continue in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Shortage of eating disorder specialists
Wider context from the report “(1) Inadequate training of doctors and other medical professionals re eating disorders
Evidence from a wide range of clinicians who had engaged with Averil in 2012 echoed the evidence of clinicians attending the four inquests of the women referred to above. All five inquests revealed a common theme of wide-spread and continuing lack of training, knowledge, or experience on the part of physicians and medical staff (including GPs and nurse practitioners, as well as acute hospital doctors, nurses and dieticians) regarding eating disorders (EDs) and specifically Anorexia Nervosa (AN). Many witnesses (from both the death 2012 and those in 2017/2018) conceded that they had only the most superficial knowledge of the often complex issues relating to recognition, monitoring, management and treatment of EDs and AN specifically. Their evidence often reflected a lack of familiarity with the King’s College Guidance for the treatment of AN in the community. The evidence of hospital staff revealed, at best, inconsistent implementation of the Royal College of Psychiatrists MARSIPAN guidance for the emergency treatment of AN patients and, at worst, a failure to implement the Guidance at all.
Evidence at Averil’s inquest (and at those of ████████) suggested that limited progress has been made in respect of the PHSO recommendation with regard to the training of doctors and other medical professionals, (notwithstanding the further recommendations of the PACAC Follow-up Report and the Government Response to the latter’s Recommendations). These concerns have been reiterated by the Position Statement of the Royal College of Psychiatrists (PS04/20) of September 2020 “Improving core skills and competence in risk assessment and management of people with eating disorders: What all doctors need to know.”
The evidence at inquest of senior practitioners in the fields of psychiatry, psychology, acute medicine, dietetics, gastroenterology and GP practice all confirmed that there remains, as there was in 2012, a continuing and serious shortage of eating disorder specialists across the country with many Trusts finding it difficult to fill vacancies ; such shortages inevitably impact upon the level and quality of support available to primary care providers and other specialists and therefore, in my view, risks avoidable future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of formally commissioned monitoring provision for moderate to high risk Anorexia Nervosa patients
Wider context from the report “(2) Lack of formally commissioned service level agreement for the provision of robust and effective monitoring of moderate to high risk AN patients by primary or secondary care providers
Evidence confirmed that in response to the PHSO Report an Expert Reference Group (ERG) was convened by NHS England (NHSE) to address the specific recommendation for NHSE to review the existing quality and availability of services to achieve parity for adult ED services with children and young people’s ED services. The National Collaborating Centre for Mental Health (NCCMH) was commissioned to develop new guidance published in August 2019: “Adult Eating Disorders: Community, Inpatient and Intensive Day Patient Care – Guidance for Commissioners and Providers”.
However, the clear and unchallenged evidence received at Averil’s inquest confirmed that there remains a lack of formally commissioned provision for the monitoring of AN patients in primary or secondary care across large parts of the United Kingdom . Whilst the evidence received indicated that Cambridgeshire & Peterborough NHS Foundation Trust are seeking to develop models to ensure the provision of medical monitoring for all ED sufferers, including moderate to high risk patients, there are many areas in the country – including parts of the East of England Region – which still have no such formally commissioned provision. Further, unchallenged evidence identified a number of regions as not even having consultant level psychiatric in-put to the ED services that are purportedly available.
There was unanimity on the part of each of the senior clinicians who gave evidence, as well as a number of independent, instructed experts in the fields of ED and AN, that the continued absence of such monitoring and treatment provision gave rise to not only the risk of avoidable future deaths, but - in the views of many - the inevitability of the same. Evidence confirmed that whilst AN has the highest mortality of any mental disorder affecting young people and adults this should not be simply accepted and that AN and other EDs are treatable mental disorders, with even severe complications such as malnutrition safely reversible. The evidence further established that whilst in the long term primary prevention strategies including early recognition and treatment of the disease was critical, in the short to medium term, improving access to treatment and the effective monitoring of the severely ill is to be regarded as essential to address the risk of avoidable future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation COVID-19 pandemic exacerbation of eating disorder safety deficiencies
Wider context from the report “(4) The impact of the COVID 19 pandemic
I am concerned that the matters giving rise to the risk of future deaths identified at points (1) to (3) above have been - and will continue to be - significantly exacerbated by the on-going pandemic . I therefore request that responses to the above recognise and expressly address this concern.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with education and curriculum partners to develop implementation plans for the new eating-disorder training resources.
Verbatim wording from the response “We supported Beat, the eating disorders charity, in their development of new all-encompassing training resources, with expertise from the Royal College of Psychiatrists’ Faculty of Eating Disorders, which are available to use as of March 2021. They introduce students and Foundation doctors to the knowledge, skills, and tools they need to identify, diagnose and treat or refer patients. We’re working with representatives from the UK Foundation Programme as well as the” Source location 2021-0058-Response-from-General-Medical-Council-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with education providers and service partners to re-establish training opportunities and support safe progression during the pandemic.
Verbatim wording from the response “You identify a concern that the pandemic increases the risk of further deaths because it has impacted all aspects of care, including training. The pandemic has impacted on training across all countries of the UK and in different ways for the differing specialties. A lot of teaching was moved online, but the clinical experience was inevitably affected. We are working with medical schools, the MSC, the national education bodies and service providers to re-establish all training opportunities as quickly as possible. We continue to work with education providers to ensure students and doctors in training can meet their outcomes and progress safely, and we’re reviewing the impact of the pandemic on training.” Source location 2021-0058-Response-from-General-Medical-Council-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include implementation of the new training resources in medical-school quality assurance and monitor uptake to determine further work.
Verbatim wording from the response “Medical Schools Council and education and curriculum leads from individual medical schools to develop implementation plans for the new resources. Although there are pressures on space in the curriculum, encouragingly, education providers have expressed enthusiasm to make use of this helpful resource. We hope that teaching on ED will be embedded in their teaching programmes. We’ll include this in our quality assurance of medical schools in 2022 to ask about changes they implemented, or if they need further support. We hope that this will give schools time to embed the new training resource. Data from the e-Learning platform will help us to monitor uptake of the training and consider what further work is required.” Source location 2021-0058-Response-from-General-Medical-Council-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Academy of Medical Royal Colleges to identify and develop shared eating-disorder learning across postgraduate specialties.
Verbatim wording from the response “We are working with the AoMRC on the details for a process to identify and develop areas where key learning can be shared in postgraduate training across the various specialties and subspecialties. The aim of this will be to ensure high standards in core clinical areas. We have asked that one of the case studies to test the shared learning process must be ED. As the shared learning work develops, we will feed into the AoMRC’s work that these skills are needed. The process to identify and develop shared learning across specialties will consider post-qualification development as part of a programme of lifelong learning across a doctor’s career. We expect this work will begin later in 2021.” Source location 2021-0058-Response-from-General-Medical-Council-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor progress of education and training changes to assess their effectiveness.
Verbatim wording from the response “Thank you for highlighting these important issues in your report. Better care for ED is so important, especially considering its growing prevalence. We’re committed to providing workable solutions to address the risk of insufficient training, knowledge, and experience of doctors. We believe the changes we’re making to enhance medical education and training will contribute to improved patient outcomes, and we will monitor progress to ensure they are effective. I’m extremely grateful for the efforts of our partners in this work who’ve collaborated to achieve significant goals in better care for people with eating disorders.” Source location 2021-0058-Response-from-General-Medical-Council-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support development of comprehensive eating-disorder training resources for students and Foundation doctors.
Verbatim wording from the response “We supported Beat, the eating disorders charity, in their development of new all-encompassing training resources, with expertise from the Royal College of Psychiatrists’ Faculty of Eating Disorders, which are available to use as of March 2021. They introduce students and Foundation doctors to the knowledge, skills, and tools they need to identify, diagnose and treat or refer patients. We’re working with representatives from the UK Foundation Programme as well as the” Source location 2021-0058-Response-from-General-Medical-Council-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with medical schools and Beat to improve and standardise undergraduate eating-disorder education.
Verbatim wording from the response “To build a better picture of coverage in undergraduate curricula, I sent a letter to all medical schools in 2019 raising the issue and requesting details of teaching in ED. All 35 medical schools responded with helpful detail on how students are taught about ED. The survey identified some good practice but also areas where education and training could be improved. There was variability across schools in coverage, in links between teaching on mental and physical health, and in exposure to patients with ED. We are working with schools to ensure coverage is improved and especially the link between physical and mental health. We reported our findings to schools, highlighting both good practice and gaps, and suggesting schools work together to develop a shared approach.” Source location 2021-0058-Response-from-General-Medical-Council-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate with medical schools and education leads to encourage uptake of new eating-disorder training resources.
Verbatim wording from the response “The pandemic also impeded our plans for this work in 2020. We had planned to follow up with medical school Deans one year after our 2019 survey, but we decided to postpone this measure since schools faced significant disruption. Instead, we communicated with schools in other ways, by contributing to a letter HEE sent to schools encouraging uptake of the new training resources, as well as communicating directly with medical school education leads and the Medical Schools Council.” Source location 2021-0058-Response-from-General-Medical-Council-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with workforce bodies and healthcare providers to identify and implement solutions to the shortage of eating-disorder specialists.
Verbatim wording from the response “The final point you raise as part of the first concern is that there is a serious shortage of ED specialists. We’ve heard evidence of a continuing shortage of ED specialists across the country, with many trusts finding it difficult to fill vacancies. These shortages inevitably impact on the level and quality of support available to primary care providers and other specialists. Your report evidences this staffing crisis, whereby heavy workloads with insufficient staffing compounded failings in Averil’s care. Although workforce issues are not specifically within our powers, we are working with the workforce bodies and health care providers across the UK to identify and implement solutions.” Source location 2021-0058-Response-from-General-Medical-Council-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the Medical Licensing Assessment with eating-disorder content to establish a common threshold for safe practice.
Verbatim wording from the response “To keep driving improvement, we’re introducing a new way of assessing medical students, as well as international medical graduates, that will ensure they meet a common and consistent threshold for safe practice before they’re licensed to work in the UK. The Medical Licensing Assessment will be based on a comprehensive content map which sets out the range of skills and knowledge that students will be required to have and could be tested on. The content map is available on our website. It includes eating disorders. All students graduating from UK medical schools from the academic year 2024/25 will need to pass the new assessment, which will also replace our current test for international medical graduates in early 2024.” Source location 2021-0058-Response-from-General-Medical-Council-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Survey medical schools on eating-disorder teaching, report findings, and highlight good practice and curriculum gaps.
Verbatim wording from the response “To build a better picture of coverage in undergraduate curricula, I sent a letter to all medical schools in 2019 raising the issue and requesting details of teaching in ED. All 35 medical schools responded with helpful detail on how students are taught about ED. The survey identified some good practice but also areas where education and training could be improved. There was variability across schools in coverage, in links between teaching on mental and physical health, and in exposure to patients with ED. We are working with schools to ensure coverage is improved and especially the link between physical and mental health. We reported our findings to schools, highlighting both good practice and gaps, and suggesting schools work together to develop a shared approach.” Source location 2021-0058-Response-from-General-Medical-Council-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Workforce issues, including shortages of eating-disorder specialists, are outside the available powers.
Verbatim wording from the response “The final point you raise as part of the first concern is that there is a serious shortage of ED specialists. We’ve heard evidence of a continuing shortage of ED specialists across the country, with many trusts finding it difficult to fill vacancies. These shortages inevitably impact on the level and quality of support available to primary care providers and other specialists. Your report evidences this staffing crisis, whereby heavy workloads with insufficient staffing compounded failings in Averil’s care. Although workforce issues are not specifically within our powers, we are working with the workforce bodies and health care providers across the UK to identify and implement solutions.” Source location 2021-0058-Response-from-General-Medical-Council-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enforcing exactly what education providers teach about eating disorders is outside the remit.
Verbatim wording from the response “It is acknowledged that early intervention for ED is crucial to successful treatment. This means doctors have a pivotal role to play in identifying the potential that a patient presenting to them with varying symptoms may have an eating disorder. We are asking education providers to reach an agreed core set of knowledge and skills for all doctors to be able to draw on in critical meetings with patients, although enforcing exactly what education providers teach is not within our remit.” Source location 2021-0058-Response-from-General-Medical-Council-Redacted
Open published response
Concerns raised 1 Failure to consider hormonal treatment and hormonal triggers when assessing depression in menopausal or perimenopausal women 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
Sarah Jane Buckingham · 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
Sarah Jane Buckingham died by hanging at her home on 12 August 2019 after a period of depression and a recent voluntary admission to a mental health hospital. The principal concern was that hormonal treatment or hormonal changes associated with perimenopause were not considered by the mental health clinicians treating her depressive illness, despite relevant previous episodes following childbirth.
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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to consider hormonal treatment and hormonal triggers when assessing depression in menopausal or perimenopausal women
Wider context from the report “Sarah had been started on Hormone Replacement Therapy (HRT) by her GP in November 2017 as she was peri-menopausal. She began to experience and suffer from symptoms of depression once again in March 2019, and was clinically diagnosed with a depressive illness and anxiety.
It was only during a voluntary hospital admission between 28th – 30th July 2019 that Sarah had a blood test taken, which included a hormone profile. This was some four months into her illness and was only taken as 'routine'.
It transpired from the evidence at Sarah's Inquest that hormone treatment and/or hormonal triggers for depressive illness were not considered by the Mental Health Clinicians treating Sarah . I heard evidence that those treating Sarah relied on, and followed, NICE Guidelines but that NICE Guidance on Depression does not say anything about the routine monitoring of hormones, or that consideration be given to this potential contributory factor when treating menopausal or perimenopausal women . The significant impact of changing hormones was considered very early on in Sarah's treatment for PND, but was not considered at all during her last episode of depression ; with no justification or explanation as to why the impact of changing hormones was considered significant after birth, but not significant during menopause. I believe that an early consideration of these issues when treating a menopausal patient, and understanding of the potential interplay between hormonal changes and depression, may assist in formulating an effective treatment plan for patients such as Sarah.
” Open source report
1 Dec 2020 Peter James Michael Unsworth · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Failure to document received specialist advice and confirm understanding View source Failure to confirm and record specialist advice View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Peter James Michael Unsworth · 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
Peter James Michael Unsworth had a history of deep vein thromboses and was taking long-term anticoagulant medication before a right hip replacement. After developing an infected hip and undergoing surgery, his anticoagulant dose was reduced following haematological advice that was not recorded in writing; he subsequently developed pulmonary emboli and died at home on 29 July 2018. The principal concern was that the lack of written records may have led to a misunderstanding of the advice given and its significance.
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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to document received specialist advice and confirm understanding
Wider context from the report “The evidence showed that:
1. The advice provided by the Consultant Haematologist related to a very complex medical situation. It was not recorded in writing. The Consultant Orthopaedic surgeon did not record it in the patient’s records nor email his understanding of the advice to the Consultant Haematologist for confirmation of what he understood the advice to be.
2. The Consultant Haematologist did not confirm her advice in writing or make any record of the advice given.
3. As a consequence, there may have been a misunderstanding of the basis on which the advice was sought and/or given, and of the import of the advice.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm and record specialist advice
Wider context from the report “The evidence showed that:
1. The advice provided by the Consultant Haematologist related to a very complex medical situation. It was not recorded in writing. The Consultant Orthopaedic surgeon did not record it in the patient’s records nor email his understanding of the advice to the Consultant Haematologist for confirmation of what he understood the advice to be.
2. The Consultant Haematologist did not confirm her advice in writing or make any record of the advice given.
3. As a consequence, there may have been a misunderstanding of the basis on which the advice was sought and/or given, and of the import of the advice.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for recording telephone advice was considered to rest with the recipient, not the doctor providing the advice.
Verbatim wording from the response “Furthermore, the information we received indicated that it would normally be for the recipient of the advice to record it in the medical notes, and where a doctor is giving advice over the phone, the person giving the advice would not always be expected to record it.” Source location 2020-0267-Further-response-from-GMC-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The completed hospital Significant Incident investigation was considered to have addressed the issues, so no further regulatory action was required.
Verbatim wording from the response “Taking this information into consider, it appears that the responsibility of ensuring a written record was made, did not lie with Dr ████████. We can see that there has been a full SI investigation which has addressed these issues, as such we don’t consider any further action is required by the GMC regarding Dr ████████.”” Source location 2020-0267-Further-response-from-GMC-Redacted
Open published response
3 Apr 2020 Andrew Spencer Wing · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Failure to provide radiographers with the differential diagnosis when requesting remote X-ray review View source Insufficiently detailed clinical information for radiographer X-ray reviews View source Failure to undertake CT aorta imaging when aortic dissection is in the differential diagnosis 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
Andrew Spencer Wing · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew Spencer Wing had a history of untreated hypertension and was discharged from hospital after investigations for acute left-sided pain, without a CT aorta being undertaken. He subsequently died from the effects of an aortic dissection. The principal concerns were that the chest X-ray and recognised possibility of aortic dissection should have led to a CT aorta, and that radiographers reviewing X-rays were given sparse clinical information.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide radiographers with the differential diagnosis when requesting remote X-ray review
Wider context from the report “1. The chest Xray taken on the 13th January 2019 showed an image which was at least at the upper end of normal and in the context of a differential diagnosis of aortic dissection should have led to a CT Aorta being undertaken. Plain X rays are not diagnostic of aortic dissections. The consultant radiographer who reviewed the X ray remotely on the 14th January 2019 reported it as normal but had not been made aware of the differential diagnosis of aortic dissection . If he had been made aware of this he would have advised that a CT Aorta be undertaken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Insufficiently detailed clinical information for radiographer X-ray reviews
Wider context from the report “2. It is common practice for reviews of X rays to be undertaken by radiographers. The clinical information provided to them is sparse. More detailed and specific information would assist them in undertaking their reviews.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake CT aorta imaging when aortic dissection is in the differential diagnosis
Wider context from the report “1. The chest Xray taken on the 13th January 2019 showed an image which was at least at the upper end of normal and in the context of a differential diagnosis of aortic dissection should have led to a CT Aorta being undertaken . Plain X rays are not diagnostic of aortic dissections. The consultant radiographer who reviewed the X ray remotely on the 14th January 2019 reported it as normal but had not been made aware of the differential diagnosis of aortic dissection. If he had been made aware of this he would have advised that a CT Aorta be undertaken.
” Open source report
2 Mar 2020 HARRY RICHFORD · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 20 Lack of cross-site clinical working opportunities View source Failure to notify the Coroner of a child death View source Uncertain auditing and logging of neonatal resuscitation pro forma completion View source Unclear guidance for obtaining anaesthetic help in paediatric emergencies View source Failure to retain placentae for examination after severe foetal distress View source Lack of clear requirements for consultant assessment of locum competence before overnight responsibility View source Failure to produce timely and sufficiently detailed statements after deaths View source Failure to assess and supervise locum clinicians View source Lack of clarity about when to call a consultant at night View source Failure to record consultant telephone advice View source Failure to record feedback and audit locum recruitment View source Insufficient consultant availability for night-time emergencies View source Lack of staff knowledge of applicable clinical guidelines and policies View source Failure to share important independent safety reports with staff View source Lack of paediatric team knowledge of neonatal collapse guidelines View source Lack of clarity about prompt action in obstetric emergencies View source Substandard obstetric record keeping View source Inaccurate and incomplete child death notification forms View source Inadequate neonatal resuscitation training View source Inaccurate MBRRACE maternal and neonatal death reporting View source See 17 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
HARRY RICHFORD · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Harry Richford was born at QEQM on 2 November 2017 and died at William Harvey Hospital on 9 November 2017 after being transferred there. The report describes delays in delivery, shortcomings in the caesarean delivery and neonatal resuscitation, and subsequent hypoxia and brain injury. Substantive concerns included locum recruitment, assessment and supervision; clarity about escalation to consultants; neonatal resuscitation training; record keeping and adherence to guidelines; and inaccurate death notifications and reporting.
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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of cross-site clinical working opportunities
Wider context from the report “Concern 8
Prior to Harry's death both ████████████████, a senior member of staff who had the care of Harry at the William Harvey Hospital, accepted that there were no opportunities for cross site working between QEQM and the William Harvey Hospital . Currently two out of eight middle grade doctors have had the opportunity to spend time at the William Harvey, which has a much higher specification neo natal unit. ████████ described the lack of opportunities before Harry's death as ‘at best, very surprising'.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the Coroner of a child death
Wider context from the report “Concern 17
The child death notification form was incorrectly completed in that Harry's death was recorded as 'expected'. No notification was made to the Coroner . No details were filled in on the notification form giving any detail of the problems leading to Harry's death. As a result, the Child Death Overview Panel would have been unaware of the problems encountered and could not have shared learning to prevent other such deaths occurring. I make no recommendation in respect of the lack of notification to the Coroner as I am aware that the Senior Coroner has already dealt with this.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Uncertain auditing and logging of neonatal resuscitation pro forma completion
Wider context from the report “Concern 15
The East Kent Trust should consider a review as to the use or otherwise of a resuscitation pro forma. A pro forma has since Harry's death been adopted by the East Kent Trust which, on the evidence of ████████, has improved the oversight of neo natal training and governance. It is not clear whether that pro forma is being audited or logged , or what actions are being done to ensure its completion and preservation.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Unclear guidance for obtaining anaesthetic help in paediatric emergencies
Wider context from the report “Concern 9
The resuscitation of Harry was eventually carried out by ████████, the anaesthetist looking after ████████. His evidence was that leaving his own patient to help the paediatric team was an unusual action to take in the UK although he had often performed such actions in Nepal. Doctors at QEQM indicated that there was an informal policy that if a middle grade paediatrician found themselves in an emergency, they could seek help from their anaesthetic colleagues . It was unclear whether the anaesthetists were aware of this informal policy . This informal policy should be clarified, and guidance given because there is a risk, that in an emergency, it will be overlooked .
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to retain placentae for examination after severe foetal distress
Wider context from the report “Concern 12
The placenta of Harry was not retained . Examination of the placenta will in some circumstances assist in cases of severe foetal distress. The Royal College of Pathologists states that it is 'essential' for the placenta to be sent for examination in cases of severe foetal distress requiring admission to a neo natal unit.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear requirements for consultant assessment of locum competence before overnight responsibility
Wider context from the report “Concern 2
The current policy of the East Kent Trust states that it is the responsibility of the healthcare professional who will be supervising the locum to assure themselves of his/her competence. This did not happen in this case. There is at present no requirement for a locum to be assessed on a day shift by a consultant before being left in charge overnight . There is no clear direction that it is the responsibility of the assessing consultant to satisfy themselves of the locum's experience and capability . One specialist from outside the East Kent Trust, ████████, also stated that it would assist the assessing consultants to be able to see not only the locum's CV but also their references and any training records available.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to produce timely and sufficiently detailed statements after deaths
Wider context from the report “Concern 16
In order to try to prevent future deaths it is important that there are clear records and statements made when a death occurs so that lessons can be learnt. In this instance many of the statements were very scanty in their content and some were made a long time after the event . In some instances, staff had to make statements from memory without the advantage of seeing the medical notes . Contemporaneous (or as near as possible) notes are also very much in the interests of the staff involved so that they can give clear accounts of their actions and reasons for them if required to do so at a later date.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and supervise locum clinicians
Wider context from the report “Concern 1
████████ was recruited as a locum registrar by the Hospital Trust without there appearing to have been any assessment of his skills and abilities or any supervision of him at the hospital . This was not an emergency appointment after, for example, a doctor calling in sick at the last minute. ████████ gave evidence that the recruitment, assessment and supervision of locums is a national problem and that there is a need for a review on a national level. This raises concerns that there may be a risk to other lives both at this trust and at other trusts in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about when to call a consultant at night
Wider context from the report “Concern 5
There appeared to be from the evidence given at the inquest substantial confusion amongst staff as to when a consultant should be called at night . The East Kent Trust now has some 70 hours a week consultant attendance on the wards. That leaves 14 hours a day when there is no consultant present. Staff, whether doctors, nurses or midwives should know the circumstances in which consultant help should be sought and should not feel inhibited from making their views known. If staff are unaware or unsure of when the consultant should be called that potentially poses a continuing risk to life.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record consultant telephone advice
Wider context from the report “Concern 14
There are no current records kept by consultants who are telephoned at home for advice . In this case there was a dispute about the number of calls made to ████████ and as to the content of these calls. The advice given and the actions taken as a result are important for the preservation of life.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record feedback and audit locum recruitment
Wider context from the report “Concern 3
████████ had worked two night time shifts at the QEQM before the night of Harry's birth. The extent to which there was any feedback from the consultants on call those two nights to ████████ is unclear. She, erroneously, believed the East Kent Trust had employed ████████. There is no record of any written feedback . From the evidence of the medical director of the East Kent Trust it appears that the current locum recruitment policy is not being checked or audited . There is a potential for further risks to life arising from these shortfalls.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient consultant availability for night-time emergencies
Wider context from the report “Concern 6
The current contracts at the East Kent Trust permit consultants to live up to 30 minutes travel time from the hospital . This poses considerable problems and risks for night time emergencies .
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge of applicable clinical guidelines and policies
Wider context from the report “Concern 10
There appeared to be considerable confusion among members of staff as to which, if any, guidelines and policies affected them . While two senior members of staff, ████████████████ (consultant), said that the East Kent Trust has systems in place to ensure knowledge of and compliance with Trust policies neither of them was able to say whether this was effective. Significant issues remain as to the knowledge of staff as to which guidelines govern their behaviour (this was also a finding of the Health and Safety Investigation Board in 2019). Such confusion or lack of knowledge increases the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to share important independent safety reports with staff
Wider context from the report “Concern 19
Important independent reports do not appear to have been shared within the East Kent Trust's staff , for instance the HSIB report into Harry's death appeared during the inquest to be unknown to a number of the staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of paediatric team knowledge of neonatal collapse guidelines
Wider context from the report “Concern 11
There was a lack of knowledge within the paediatric team of guidelines issued by the Department of Women's Health . The evidence from the East Kent Trust doctors was that the guidelines issued by the department directed to 'all maternity and neonatal staff who may be involved with the immediate care and support of a collapsed neonate' would not have been known to the paediatric team at the relevant time. Even senior clinicians, such as ████████, were not aware of the relevant guidelines.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about prompt action in obstetric emergencies
Wider context from the report “Concern 4
There is a risk to the life of both mothers and babies if there is a lack of clarity as to the processes or the need to take prompt action where it is necessitated in the event of an obstetric concern or emergency developing.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Substandard obstetric record keeping
Wider context from the report “Concern 13
The standard of record keeping on the obstetric unit was substantially sub-standard . The quality of the note taking and records is of considerable importance to new staff taking over responsibility for mother and baby. Without there being clear accurate records there is a risk of further mistakes being made leading, at the worst, to the risk of death. An example of this in Harry's case is that the record of the syntocinon prescribed to ████████ over a long period of time is inconsistent with the evidence of the midwives and the registrar who gave it to her.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Inaccurate and incomplete child death notification forms
Wider context from the report “Concern 17
The child death notification form was incorrectly completed in that Harry's death was recorded as 'expected' . No notification was made to the Coroner. No details were filled in on the notification form giving any detail of the problems leading to Harry's death . As a result, the Child Death Overview Panel would have been unaware of the problems encountered and could not have shared learning to prevent other such deaths occurring. I make no recommendation in respect of the lack of notification to the Coroner as I am aware that the Senior Coroner has already dealt with this.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate neonatal resuscitation training
Wider context from the report “Concern 7
The evidence of ████████ raised substantial concerns about the quality of training and learning in respect of neonatal resuscitation at the East Kent Trust. His evidence was that it would be desirable for middle grade doctors to attend the ARNI course (the advanced resuscitation of the new born infant). He also recommended that there should be simulated drills in neo natal resuscitation.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Inaccurate MBRRACE maternal and neonatal death reporting
Wider context from the report “Concern 18
The MBRRACE form in respect of Harry Richford was inaccurate in a number of important areas . The form is important to provide robust national data to support the delivery of safe, high quality maternal and new born care as well as identifying errors and faults, if any, where there has been a maternal or infant death so that future deaths can be avoided.
” Open source report
24 Dec 2019 Ifeoma Onwuka · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 5 Lack of clinical leadership and oversight of care View source Lack of professional curiosity about the cause of DIC View source Lack of on-call consultant capability to perform emergency surgery independently View source Reluctance of the on-call consultant to consider non-conservative management View source Lack of ability to work in or lead a clinical team 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
Ifeoma Onwuka · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Onwuka was admitted for induction of labour and developed severe bleeding and disseminated intravascular coagulopathy after delivering her baby. She underwent a hysterectomy after a delay, and an expert concluded that the delay in surgery to control the bleeding contributed to her death. The principal concerns were apparent lack of confidence in performing emergency hysterectomy, inadequate investigation of the cause of the coagulopathy, and lack of leadership and overview of her care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical leadership and oversight of care
Wider context from the report “1. Apparent lack of confidence/ability on part of on-call consultant to perform an emergency total abdominal hysterectomy without another consultant present.
2. Lack of professional curiosity about cause of DIC, the haemorrhage was not enough to cause this.
3. Lack of leadership and overview of Mrs Onwuka’s care . Reluctance on the part of the on-call consultant to consider anything other than conservative measures until another obstetric consultant was present.
That pregnant women in the area served by this hospital may be at risk if emergency surgery is needed and this consultant has these apparent difficulties, continues with an apparent lack of professional curiosity and displays no evidence of the ability to work in a team or head a team .
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of professional curiosity about the cause of DIC
Wider context from the report “1. Apparent lack of confidence/ability on part of on-call consultant to perform an emergency total abdominal hysterectomy without another consultant present.
2. Lack of professional curiosity about cause of DIC , the haemorrhage was not enough to cause this.
3. Lack of leadership and overview of Mrs Onwuka’s care. Reluctance on the part of the on-call consultant to consider anything other than conservative measures until another obstetric consultant was present.
That pregnant women in the area served by this hospital may be at risk if emergency surgery is needed and this consultant has these apparent difficulties, continues with an apparent lack of professional curiosity and displays no evidence of the ability to work in a team or head a team.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of on-call consultant capability to perform emergency surgery independently
Wider context from the report “1. Apparent lack of confidence/ability on part of on-call consultant to perform an emergency total abdominal hysterectomy without another consultant present.
2. Lack of professional curiosity about cause of DIC, the haemorrhage was not enough to cause this.
3. Lack of leadership and overview of Mrs Onwuka’s care. Reluctance on the part of the on-call consultant to consider anything other than conservative measures until another obstetric consultant was present.
That pregnant women in the area served by this hospital may be at risk if emergency surgery is needed and this consultant has these apparent difficulties , continues with an apparent lack of professional curiosity and displays no evidence of the ability to work in a team or head a team.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Reluctance of the on-call consultant to consider non-conservative management
Wider context from the report “1. Apparent lack of confidence/ability on part of on-call consultant to perform an emergency total abdominal hysterectomy without another consultant present.
2. Lack of professional curiosity about cause of DIC, the haemorrhage was not enough to cause this.
3. Lack of leadership and overview of Mrs Onwuka’s care. Reluctance on the part of the on-call consultant to consider anything other than conservative measures until another obstetric consultant was present.
That pregnant women in the area served by this hospital may be at risk if emergency surgery is needed and this consultant has these apparent difficulties, continues with an apparent lack of professional curiosity and displays no evidence of the ability to work in a team or head a team.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of ability to work in or lead a clinical team
Wider context from the report “1. Apparent lack of confidence/ability on part of on-call consultant to perform an emergency total abdominal hysterectomy without another consultant present.
2. Lack of professional curiosity about cause of DIC, the haemorrhage was not enough to cause this.
3. Lack of leadership and overview of Mrs Onwuka’s care. Reluctance on the part of the on-call consultant to consider anything other than conservative measures until another obstetric consultant was present.
That pregnant women in the area served by this hospital may be at risk if emergency surgery is needed and this consultant has these apparent difficulties, continues with an apparent lack of professional curiosity and displays no evidence of the ability to work in a team or head a team .
” Open source report
29 Nov 2019 LEAH LOUISE CAMBRIDGE · Prevention of Future Deaths report West Yorkshire (East)
View report summary
Concerns raised 3 Lack of prescribed regulatory guidance on BBL surgical techniques View source Lack of regulatory intervention and control of BBL procedures in the UK View source Failure to obtain informed consent for BBL procedures View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
LEAH LOUISE CAMBRIDGE · 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
Leah Louise Cambridge, aged 29, travelled to Izmir, Turkey, for a Brazilian Butt Lift under general anaesthetic and died during the procedure on 27 August 2018. A post-mortem examination found that fat had entered veins in her body, causing a fat embolism. The concerns included continued UK involvement in BBL procedures, inadequate informed consent, and a lack of regulatory intervention and control.
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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of prescribed regulatory guidance on BBL surgical techniques
Wider context from the report “(3) If BBL procedures continue to be permitted in the UK, I consider there is a need for the regulatory authorities to consider prescribing guidance on the surgical techniques to be employed and the information to be provided before a person incurs expense.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory intervention and control of BBL procedures in the UK
Wider context from the report “(1) Notwithstanding
(a) the death of Ms Cambridge on 27.8.18; and
(b) concerns expressed in relation to the risks involved in BBL procedures by a task force established under the auspices of the Aesthetic Surgery Education and Research Foundation (ASERF); and
(c) a voluntary moratorium declared by the British Association of Aesthetic and Plastic Surgeons (‘BAAPS’)
The Inquest heard evidence that some plastic surgeons in the UK continue to carry out BBL procedures. Furthermore, that Elite Aftercare continue to facilitate other clients to travel to Turkey for the purpose of BBL procedures to be undertaken by surgeons such as ████████.
I am concerned at the lack of intervention and control of BBL procedures by the regulatory authorities in the UK.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain informed consent for BBL procedures
Wider context from the report “(2) In order to make an informed decision as to the wisdom of undertaking effective cosmetic surgical procedures such as BBL, it is important that the person involved receive adequate information regarding the mortality and morbidity risks involved . In order to read and absorb such information it needs to be provided prior to any commitment being made or expense incurred . The Inquest into the death of Ms Cambridge heard that she was provided with a substantial quantity of material (some of which was written in Turkish) on the morning of the surgery and required to sign each page. The Inquest found she had insufficient time to digest this complex material, even if she was in a frame of mind to try, shortly before being taken to theatre. My concern is that informed consent is not obtained.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish revised consent guidance with tailored specialty materials emphasising time for patients to consider treatment information.
Verbatim wording from the response “We will be publishing a revised version of the guidance later this year which will place even greater emphasis on giving adequate time for a patient to digest the information and reach a decision about treatment. It will be supported by tailored materials for specialties where we know there are issues with applying the guidance in practice.” Source location 2019-0408-Response-from-the-General-Medical-Council-1
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clinical guidance on surgical techniques is the role of other bodies, such as the Royal Colleges of Surgeons.
Verbatim wording from the response “We do not provide clinical guidance on surgical techniques, that is the role of other bodies such as the Royal Colleges of Surgeons.” Source location 2019-0408-Response-from-the-General-Medical-Council-1
Open published response
23 May 2019 Sasha Sabrina FORSTER · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 6 Risk of using prescribed Propranolol for overdose View source Failure to agree and update a common action plan for revoked s.17 leave View source Failure to collect and return patients to the ward when s.17 leave is revoked View source Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol View source Failure to finalise the formal revocation of s.17 leave View source Lack of shared awareness of powers and responsibilities when s.17 leave is revoked View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sasha Sabrina FORSTER · 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
Sasha Sabrina FORSTER, a 20-year-old woman with a lengthy history of mental health disorders, self-harm and overdoses, died by suicide following deliberate ingestion of a fatal overdose of Propranolol tablets. The inquest identified concerns that hospitals and police forces were not always aware of their powers and responsibilities when her section 17 leave was revoked, or had not agreed and updated a common plan, resulting in inconsistent actions and an increased risk to Sasha.
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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Risk of using prescribed Propranolol for overdose
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it .
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to agree and update a common action plan for revoked s.17 leave
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked, or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances .
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to collect and return patients to the ward when s.17 leave is revoked
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked , was that they did not have the resources to allow them to do this , despite it being their legal responsibility so to do .
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked , placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised, Sasha’s mother was given to believe that it would be, and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to finalise the formal revocation of s.17 leave
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked, was that they did not have the resources to allow them to do this, despite it being their legal responsibility so to do.
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked, placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised , Sasha’s mother was given to believe that it would be , and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of shared awareness of powers and responsibilities when s.17 leave is revoked
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked , or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances.
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate relevant prescribing guidance extracts to support safe prescribing and patient safety.
Verbatim wording from the response “With regards to prescribing, the GMC’s guidance is clear that a doctor must only prescribe when they have adequate knowledge of the patient’s health. This will involve making an assessment, together with the patient, of their condition and having, or taking, an adequate history.” Source location Sasha-Forster-R2019-01694
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refer information about the private GPs to an Assistant Registrar to determine whether the investigation threshold is met.
Verbatim wording from the response “Conduct of individual doctors
When a doctor fails to adhere to our ethical guidance the GMC must establish whether our threshold for investigation has been met; namely, whether the doctor’s conduct, if proven, is capable of amounting to impaired fitness to practise to a degree warranting action on their registration.” Source location Sasha-Forster-R2019-01694
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing prescribing guidance is considered sufficient to ensure safe prescribing and protect patient safety when followed.
Verbatim wording from the response “I have enclosed extracts of the relevant sections of our ethical guidance at Annex A of this letter; and, we consider that this guidance, when followed, ensures safe prescribing and protects patient safety.” Source location Sasha-Forster-R2019-01694
Open published response
5 Apr 2019 Jennifer Louise Handy · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2 Failure to complete investigations and inquests View source Failure to ensure doctors who have worked in the UK remain traceable and accountable when their conduct is questioned View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jennifer Louise Handy · 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
Jennifer Louise Handy was born at 26 weeks plus 4 days gestation at home on 10th April 2017 and was too premature to survive. The report raised concerns that the doctor involved could not be traced or held to account, which diminished the quality and completeness of the investigation and limited his ability to learn from the issues identified.
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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to complete investigations and inquests
Wider context from the report “No account in any format was ever provided by Dr A, the Registrar who treated Mrs Handy on 9th April 2017 and sent her home with laxatives and paracetamol. He left the UK in April 2017 to return to his native Sri Lanka to work and thereafter could not be traced.
It is unacceptable that any doctor who has worked in the UK should not be easily traceable and held to account where their conduct is in question.
The risk of future deaths arises as the quality of this investigation/inquest was diminished because it was incomplete , and the doctor in question has been unable to learn from the issues raised.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure doctors who have worked in the UK remain traceable and accountable when their conduct is questioned
Wider context from the report “No account in any format was ever provided by Dr A, the Registrar who treated Mrs Handy on 9th April 2017 and sent her home with laxatives and paracetamol. He left the UK in April 2017 to return to his native Sri Lanka to work and thereafter could not be traced.
It is unacceptable that any doctor who has worked in the UK should not be easily traceable and held to account where their conduct is in question.
The risk of future deaths arises as the quality of this investigation/inquest was diminished because it was incomplete, and the doctor in question has been unable to learn from the issues raised.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish professional guidance requiring doctors to disclose relevant disciplinary findings made by professional bodies worldwide.
Verbatim wording from the response “In addition, GMC guidance also sets a requirement for doctors to disclose relevant disciplinary information to the GMC. Specifically, paragraph 75 of GMP states that... 'You must tell us without delay if, anywhere in the world another professional body has made a finding against your registration as a result of fitness to practise procedures.'” Source location 2019-0121-Response-by-General-Medical-Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish professional guidance requiring doctors to cooperate with formal inquiries and complaints procedures and provide relevant information.
Verbatim wording from the response “There are provisions in the GMC’s main guidance document in relation to a doctor’s professional obligation to assist with formal proceedings.” Source location 2019-0121-Response-by-General-Medical-Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide public online access to doctors’ fitness-to-practise histories and registration restrictions through the List of Registered Medical Practitioners.
Verbatim wording from the response “There are currently systems in place so that employers can access information about matters relating to a doctor’s fitness to practise.” Source location 2019-0121-Response-by-General-Medical-Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing systems, including the public medical register, sufficiently allow employers to access doctors’ fitness-to-practise information.
Verbatim wording from the response “There are currently systems in place so that employers can access information about matters relating to a doctor’s fitness to practise.” Source location 2019-0121-Response-by-General-Medical-Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing statutory requirements and powers sufficiently ensure that GMC-registered doctors maintain effective contact details.
Verbatim wording from the response “The Act already makes provision for the GMC to take action on a doctor’s registration for failing to maintain an effective registered address.” Source location 2019-0121-Response-by-General-Medical-Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There is no legal basis to require doctors to provide contact details after their GMC registration has ended.
Verbatim wording from the response “In terms of the first interpretation, the GMC’s statutory powers extend only to doctors who hold GMC registration. As such, there is no legal basis to require doctors to provide their contact details to the GMC once their registration has ended.” Source location 2019-0121-Response-by-General-Medical-Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The GMC cannot legally compel doctors to engage in coroners’ proceedings, although professional standards require cooperation with formal inquiries.
Verbatim wording from the response “As explained above, the legal and professional requirements of doctors arise from legislation and professional standards documents produced by the GMC, as opposed to there being any contractual relationship between the parties.” Source location 2019-0121-Response-by-General-Medical-Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing information-sharing mechanisms and disclosure requirements sufficiently protect patient safety when doctors face proceedings in other jurisdictions.
Verbatim wording from the response “There are already mechanisms in place for overseas regulators to share information regarding disciplinary action or criminal sanctions in relation to doctors working in other jurisdictions.” Source location 2019-0121-Response-by-General-Medical-Council
Open published response
5 Nov 2018 Name not published · Prevention of Future Deaths report London Inner South
View report summary
Concerns raised 6 Failure to examine patients’ past records in full View source Medication prescribing errors involving incorrect doses View source Failure to record clinical presentations, diagnoses, medication-change rationale and attendances View source Failure to provide urgent psychiatric referral when clinically needed View source Failure to inquire into psychiatric history when presentation warrants further inquiry View source Inappropriate prescribing of large medication quantities during an initial medication switch 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
Name not published · 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
The deceased died at St Thomas’s Hospital on 22 November 2017 from brain damage sustained after he hanged himself at home on 20 November 2017. Concerns included changes and prescribing of psychiatric and sedative medication, inadequate clinical records and review of past records, failure to make an urgent psychiatric referral, and uncertainty about the medication found after his death and what he had taken.
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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to examine patients’ past records in full
Wider context from the report “3. On 5 October 2017 the deceased saw Dr A again. The Zolpidem was swapped to Nitrazepam, a more potent sedative, as the deceased had said that after 2 weeks he had not found the Zolpidem to be effective. Expert evidence adduced at the inquest from ████████ was to the effect that the deceased’s presentation at this point should have triggered a further inquiry into his psychiatric history. ████████ said that he would have contacted the deceased’s home GP.
4. On 19 October 2017 the deceased saw Dr A again. He said he was feeling better on the Duloxetine but was still stressed and anxious and got a few anxiety attacks. Dr A prescribed him Propranolol, Nitrazepam and Xanax. Dr A also prescribed the deceased 6 months’ worth of Duloxetine. ████████ evidence was that it was “most unusual” to prescribe such a large amount of medication (6 months’ worth of Duloxetine) during the initial period where a patient’s medication had been switched and where close monitoring was needed. He opined that the first 6 weeks of the ‘switch’ period were ones in which the patient might get worse before getting better, might get worse and might develop suicidal thoughts. ████████ said that such a volume of medication was not merited clinically and could create a risk of overdose.
5. On 8 and 9 November 2017 the deceased saw Dr B. She made no notes of his presentation or diagnosis on any occasion when she saw him which she accepted she should have done. She also did not note her rationale for changing his medication which again ████████ said should have happened. He also considered that Dr B should have examined the past records for the deceased which she accepted she had not done in full .
6. There are a series of further issues with the medication Dr B prescribed the deceased and her records of the same. The electronic patient notes reflect a prescription for Xanax but she said in evidence that the deceased had not in fact accepted this. She prescribed him Temazepam but this is a controlled drug in this country and cannot be prescribed in the usual way. She changed this to Nitrazepam but the dose was incorrect and this was refused by the pharmacy. The next day she prescribed him Lorazepam without him returning the Nitrazepam prescription to her. She made an error in the dose for Lorazepam and had to correct that. When he attended on 15 November 2017 asking for more medication she made no note of his attendance.
7. ████████ evidence was that the multiple changes to the medication regime made by Dr B were not medically indicated and that the deceased had needed an urgent psychiatric referral. He said this was the case by 8 November 2017.
8. Overall ████████ said his impression was that Dr B did not understand what she was prescribing.
9. I accepted ████████ opinion on the various issues set out above.
10. Large numbers of boxes of medication were found at the deceased’s flat after his death by the police and his family. There remains some uncertainty as to where he obtained all the medication from, and what exactly he had taken and when.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Medication prescribing errors involving incorrect doses
Wider context from the report “3. On 5 October 2017 the deceased saw Dr A again. The Zolpidem was swapped to Nitrazepam, a more potent sedative, as the deceased had said that after 2 weeks he had not found the Zolpidem to be effective. Expert evidence adduced at the inquest from ████████ was to the effect that the deceased’s presentation at this point should have triggered a further inquiry into his psychiatric history. ████████ said that he would have contacted the deceased’s home GP.
4. On 19 October 2017 the deceased saw Dr A again. He said he was feeling better on the Duloxetine but was still stressed and anxious and got a few anxiety attacks. Dr A prescribed him Propranolol, Nitrazepam and Xanax. Dr A also prescribed the deceased 6 months’ worth of Duloxetine. ████████ evidence was that it was “most unusual” to prescribe such a large amount of medication (6 months’ worth of Duloxetine) during the initial period where a patient’s medication had been switched and where close monitoring was needed. He opined that the first 6 weeks of the ‘switch’ period were ones in which the patient might get worse before getting better, might get worse and might develop suicidal thoughts. ████████ said that such a volume of medication was not merited clinically and could create a risk of overdose.
5. On 8 and 9 November 2017 the deceased saw Dr B. She made no notes of his presentation or diagnosis on any occasion when she saw him which she accepted she should have done. She also did not note her rationale for changing his medication which again ████████ said should have happened. He also considered that Dr B should have examined the past records for the deceased which she accepted she had not done in full.
6. There are a series of further issues with the medication Dr B prescribed the deceased and her records of the same. The electronic patient notes reflect a prescription for Xanax but she said in evidence that the deceased had not in fact accepted this. She prescribed him Temazepam but this is a controlled drug in this country and cannot be prescribed in the usual way. She changed this to Nitrazepam but the dose was incorrect and this was refused by the pharmacy . The next day she prescribed him Lorazepam without him returning the Nitrazepam prescription to her. She made an error in the dose for Lorazepam and had to correct that . When he attended on 15 November 2017 asking for more medication she made no note of his attendance.
7. ████████ evidence was that the multiple changes to the medication regime made by Dr B were not medically indicated and that the deceased had needed an urgent psychiatric referral. He said this was the case by 8 November 2017.
8. Overall ████████ said his impression was that Dr B did not understand what she was prescribing.
9. I accepted ████████ opinion on the various issues set out above.
10. Large numbers of boxes of medication were found at the deceased’s flat after his death by the police and his family. There remains some uncertainty as to where he obtained all the medication from, and what exactly he had taken and when.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record clinical presentations, diagnoses, medication-change rationale and attendances
Wider context from the report “3. On 5 October 2017 the deceased saw Dr A again. The Zolpidem was swapped to Nitrazepam, a more potent sedative, as the deceased had said that after 2 weeks he had not found the Zolpidem to be effective. Expert evidence adduced at the inquest from ████████ was to the effect that the deceased’s presentation at this point should have triggered a further inquiry into his psychiatric history. ████████ said that he would have contacted the deceased’s home GP.
4. On 19 October 2017 the deceased saw Dr A again. He said he was feeling better on the Duloxetine but was still stressed and anxious and got a few anxiety attacks. Dr A prescribed him Propranolol, Nitrazepam and Xanax. Dr A also prescribed the deceased 6 months’ worth of Duloxetine. ████████ evidence was that it was “most unusual” to prescribe such a large amount of medication (6 months’ worth of Duloxetine) during the initial period where a patient’s medication had been switched and where close monitoring was needed. He opined that the first 6 weeks of the ‘switch’ period were ones in which the patient might get worse before getting better, might get worse and might develop suicidal thoughts. ████████ said that such a volume of medication was not merited clinically and could create a risk of overdose.
5. On 8 and 9 November 2017 the deceased saw Dr B. She made no notes of his presentation or diagnosis on any occasion when she saw him which she accepted she should have done. She also did not note her rationale for changing his medication which again ████████ said should have happened. He also considered that Dr B should have examined the past records for the deceased which she accepted she had not done in full.
6. There are a series of further issues with the medication Dr B prescribed the deceased and her records of the same. The electronic patient notes reflect a prescription for Xanax but she said in evidence that the deceased had not in fact accepted this. She prescribed him Temazepam but this is a controlled drug in this country and cannot be prescribed in the usual way. She changed this to Nitrazepam but the dose was incorrect and this was refused by the pharmacy. The next day she prescribed him Lorazepam without him returning the Nitrazepam prescription to her. She made an error in the dose for Lorazepam and had to correct that. When he attended on 15 November 2017 asking for more medication she made no note of his attendance .
7. ████████ evidence was that the multiple changes to the medication regime made by Dr B were not medically indicated and that the deceased had needed an urgent psychiatric referral. He said this was the case by 8 November 2017.
8. Overall ████████ said his impression was that Dr B did not understand what she was prescribing.
9. I accepted ████████ opinion on the various issues set out above.
10. Large numbers of boxes of medication were found at the deceased’s flat after his death by the police and his family. There remains some uncertainty as to where he obtained all the medication from, and what exactly he had taken and when.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide urgent psychiatric referral when clinically needed
Wider context from the report “3. On 5 October 2017 the deceased saw Dr A again. The Zolpidem was swapped to Nitrazepam, a more potent sedative, as the deceased had said that after 2 weeks he had not found the Zolpidem to be effective. Expert evidence adduced at the inquest from ████████ was to the effect that the deceased’s presentation at this point should have triggered a further inquiry into his psychiatric history. ████████ said that he would have contacted the deceased’s home GP.
4. On 19 October 2017 the deceased saw Dr A again. He said he was feeling better on the Duloxetine but was still stressed and anxious and got a few anxiety attacks. Dr A prescribed him Propranolol, Nitrazepam and Xanax. Dr A also prescribed the deceased 6 months’ worth of Duloxetine. ████████ evidence was that it was “most unusual” to prescribe such a large amount of medication (6 months’ worth of Duloxetine) during the initial period where a patient’s medication had been switched and where close monitoring was needed. He opined that the first 6 weeks of the ‘switch’ period were ones in which the patient might get worse before getting better, might get worse and might develop suicidal thoughts. ████████ said that such a volume of medication was not merited clinically and could create a risk of overdose.
5. On 8 and 9 November 2017 the deceased saw Dr B. She made no notes of his presentation or diagnosis on any occasion when she saw him which she accepted she should have done. She also did not note her rationale for changing his medication which again ████████ said should have happened. He also considered that Dr B should have examined the past records for the deceased which she accepted she had not done in full.
6. There are a series of further issues with the medication Dr B prescribed the deceased and her records of the same. The electronic patient notes reflect a prescription for Xanax but she said in evidence that the deceased had not in fact accepted this. She prescribed him Temazepam but this is a controlled drug in this country and cannot be prescribed in the usual way. She changed this to Nitrazepam but the dose was incorrect and this was refused by the pharmacy. The next day she prescribed him Lorazepam without him returning the Nitrazepam prescription to her. She made an error in the dose for Lorazepam and had to correct that. When he attended on 15 November 2017 asking for more medication she made no note of his attendance.
7. ████████ evidence was that the multiple changes to the medication regime made by Dr B were not medically indicated and that the deceased had needed an urgent psychiatric referral . He said this was the case by 8 November 2017 .
8. Overall ████████ said his impression was that Dr B did not understand what she was prescribing.
9. I accepted ████████ opinion on the various issues set out above.
10. Large numbers of boxes of medication were found at the deceased’s flat after his death by the police and his family. There remains some uncertainty as to where he obtained all the medication from, and what exactly he had taken and when.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to inquire into psychiatric history when presentation warrants further inquiry
Wider context from the report “3. On 5 October 2017 the deceased saw Dr A again. The Zolpidem was swapped to Nitrazepam, a more potent sedative, as the deceased had said that after 2 weeks he had not found the Zolpidem to be effective. Expert evidence adduced at the inquest from ████████ was to the effect that the deceased’s presentation at this point should have triggered a further inquiry into his psychiatric history . ████████ said that he would have contacted the deceased’s home GP.
4. On 19 October 2017 the deceased saw Dr A again. He said he was feeling better on the Duloxetine but was still stressed and anxious and got a few anxiety attacks. Dr A prescribed him Propranolol, Nitrazepam and Xanax. Dr A also prescribed the deceased 6 months’ worth of Duloxetine. ████████ evidence was that it was “most unusual” to prescribe such a large amount of medication (6 months’ worth of Duloxetine) during the initial period where a patient’s medication had been switched and where close monitoring was needed. He opined that the first 6 weeks of the ‘switch’ period were ones in which the patient might get worse before getting better, might get worse and might develop suicidal thoughts. ████████ said that such a volume of medication was not merited clinically and could create a risk of overdose.
5. On 8 and 9 November 2017 the deceased saw Dr B. She made no notes of his presentation or diagnosis on any occasion when she saw him which she accepted she should have done. She also did not note her rationale for changing his medication which again ████████ said should have happened. He also considered that Dr B should have examined the past records for the deceased which she accepted she had not done in full.
6. There are a series of further issues with the medication Dr B prescribed the deceased and her records of the same. The electronic patient notes reflect a prescription for Xanax but she said in evidence that the deceased had not in fact accepted this. She prescribed him Temazepam but this is a controlled drug in this country and cannot be prescribed in the usual way. She changed this to Nitrazepam but the dose was incorrect and this was refused by the pharmacy. The next day she prescribed him Lorazepam without him returning the Nitrazepam prescription to her. She made an error in the dose for Lorazepam and had to correct that. When he attended on 15 November 2017 asking for more medication she made no note of his attendance.
7. ████████ evidence was that the multiple changes to the medication regime made by Dr B were not medically indicated and that the deceased had needed an urgent psychiatric referral. He said this was the case by 8 November 2017.
8. Overall ████████ said his impression was that Dr B did not understand what she was prescribing.
9. I accepted ████████ opinion on the various issues set out above.
10. Large numbers of boxes of medication were found at the deceased’s flat after his death by the police and his family. There remains some uncertainty as to where he obtained all the medication from, and what exactly he had taken and when.
” 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 General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Inappropriate prescribing of large medication quantities during an initial medication switch
Wider context from the report “3. On 5 October 2017 the deceased saw Dr A again. The Zolpidem was swapped to Nitrazepam, a more potent sedative, as the deceased had said that after 2 weeks he had not found the Zolpidem to be effective. Expert evidence adduced at the inquest from ████████ was to the effect that the deceased’s presentation at this point should have triggered a further inquiry into his psychiatric history. ████████ said that he would have contacted the deceased’s home GP.
4. On 19 October 2017 the deceased saw Dr A again. He said he was feeling better on the Duloxetine but was still stressed and anxious and got a few anxiety attacks. Dr A prescribed him Propranolol, Nitrazepam and Xanax. Dr A also prescribed the deceased 6 months’ worth of Duloxetine. ████████ evidence was that it was “most unusual” to prescribe such a large amount of medication (6 months’ worth of Duloxetine) during the initial period where a patient’s medication had been switched and where close monitoring was needed . He opined that the first 6 weeks of the ‘switch’ period were ones in which the patient might get worse before getting better, might get worse and might develop suicidal thoughts. ████████ said that such a volume of medication was not merited clinically and could create a risk of overdose .
5. On 8 and 9 November 2017 the deceased saw Dr B. She made no notes of his presentation or diagnosis on any occasion when she saw him which she accepted she should have done. She also did not note her rationale for changing his medication which again ████████ said should have happened. He also considered that Dr B should have examined the past records for the deceased which she accepted she had not done in full.
6. There are a series of further issues with the medication Dr B prescribed the deceased and her records of the same. The electronic patient notes reflect a prescription for Xanax but she said in evidence that the deceased had not in fact accepted this. She prescribed him Temazepam but this is a controlled drug in this country and cannot be prescribed in the usual way. She changed this to Nitrazepam but the dose was incorrect and this was refused by the pharmacy. The next day she prescribed him Lorazepam without him returning the Nitrazepam prescription to her. She made an error in the dose for Lorazepam and had to correct that. When he attended on 15 November 2017 asking for more medication she made no note of his attendance.
7. ████████ evidence was that the multiple changes to the medication regime made by Dr B were not medically indicated and that the deceased had needed an urgent psychiatric referral. He said this was the case by 8 November 2017.
8. Overall ████████ said his impression was that Dr B did not understand what she was prescribing.
9. I accepted ████████ opinion on the various issues set out above.
10. Large numbers of boxes of medication were found at the deceased’s flat after his death by the police and his family. There remains some uncertainty as to where he obtained all the medication from, and what exactly he had taken and when.
” 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