9 Oct 2018 Tom Cribley · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 12 Failure to document important clinical findings View source Insufficient clinical staff training in identifying and treating sepsis View source Failure to escalate monitoring and management after grossly abnormal blood results View source Failure of senior leadership ownership of training programme implementation and review View source Failure to maintain systematic and monitored ongoing sepsis training View source Failure to complete full PIT STOP reviews View source Failure to hand over clinical concerns to relevant clinical staff View source Failure to escalate and convey the severity of deterioration to the Critical Care Team View source Failure to review an initial diagnosis when the patient deteriorates View source Delays in escalating NEWS to medical staff View source Delays in administering antibiotic therapy during clinical deterioration View source Failure to repeat observations hourly in accordance with the NEWS policy View source See 9 more concerns
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AI-generated summary
Tom Cribley · 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
Tom Cribley attended Aintree hospital on 18 February 2017 with vomiting, diarrhoea and a rash, and was later diagnosed with meningococcal sepsis. The report identifies concerns including failures to document and escalate the rash and deteriorating observations, inadequate handovers and reassessment, delayed recognition of abnormal blood results, and delayed antibiotic treatment. Tom did not recover and died on 20 February 2017.
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 important clinical findings
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage . The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” 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 clinical staff training in identifying and treating sepsis
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” 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 escalate monitoring and management after grossly abnormal blood results
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results , the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” 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 senior leadership ownership of training programme implementation and review
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board . This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” 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 maintain systematic and monitored ongoing sepsis training
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness .
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” 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 complete full PIT STOP reviews
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review , the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” 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 clinical concerns to relevant clinical staff
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers , the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” 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 escalate and convey the severity of deterioration to the Critical Care Team
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team , who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” 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 review an initial diagnosis when the patient deteriorates
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate , the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” 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 escalating NEWS to medical staff
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” 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 administering antibiotic therapy during clinical deterioration
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” 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 repeat observations hourly in accordance with the NEWS policy
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy . The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report
7 Mar 2018 Ms Ivanika Olivari · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 8 Failure to prioritise risk to life in urgent and emergency situations View source Failure to update relevant staff training promptly and audibly View source Department of Health guidance failing to clearly permit leaving messages for patients in urgent and emergency situations View source Failure to attempt patient contact through all available contact phone numbers in urgent and emergency situations View source GMC guidance failing to clearly permit leaving messages for patients in urgent and emergency situations View source Failure to communicate urgent and emergency guidance clarifications to doctors and relevant NHS staff View source Failure to leave answerphone messages enabling patient contact in urgent and emergency situations View source Hospital guidelines failing to reflect required urgent and emergency communication and life-risk priorities View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ms Ivanika Olivari · 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
Ms Ivanika Olivari died on 3 August 2017 at St George’s Hospital after suffering a cardiac arrest at home associated with a malfunctioning pacemaker. The principal concerns were failures to leave a message or use all available contact numbers in an urgent situation, and the need for guidance, policies and staff training to prioritise risk to life and permit appropriate messages to patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise risk to life in urgent and emergency situations
Wider context from the report “3. That in urgent and emergency situations risk to life should be considered the priority .
” 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 update relevant staff training promptly and audibly
Wider context from the report “5. That hospitals and St George's Hospital in particular, should ensure that all relevant staff have their training updated in a prompt and auditable fashion to reflect the concerns raised above.
” 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 Department of Health guidance failing to clearly permit leaving messages for patients in urgent and emergency situations
Wider context from the report “7. That the Department of Health also considers its guidance that it issues in relation to such matters, and amend where necessary to ensure that it is clear that messages may be left for patients in urgent and emergency situations .
” 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 attempt patient contact through all available contact phone numbers in urgent and emergency situations
Wider context from the report “2. That doctors should attempt to contact patients via all contact phone numbers that they have access to for patients in urgent and emergency situations.
” 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 GMC guidance failing to clearly permit leaving messages for patients in urgent and emergency situations
Wider context from the report “6. That the GMC considers its guidance for doctors and amend where necessary to ensure that it is clear that messages may be left for patients in urgent and emergency situations .
” 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 communicate urgent and emergency guidance clarifications to doctors and relevant NHS staff
Wider context from the report “8. That the GMC and Department of Health both take steps to ensure that the clarifications as outlined above are communicated to all doctors by the GMC and to all relevant staff employed by the NHS by the Department of Health .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to leave answerphone messages enabling patient contact in urgent and emergency situations
Wider context from the report “1. That doctors should leave messages on answerphones for patients to make contact with them in urgent and emergency situations .
” 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 Hospital guidelines failing to reflect required urgent and emergency communication and life-risk priorities
Wider context from the report “4. That hospital guidelines and St George’s hospital guidelines in particular , in relation to such matters, should be updated and amended to reflect the above where needed .
” 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 Review ethical guidance and identify any necessary amendments clarifying that urgent messages may be left for patients.
Verbatim wording from the response “• The GMC considers its guidance for doctors and amend where necessary to ensure that it is clear that messages may be left for patients in urgent and emergency situations.” Source location 2018-0073-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 Alert the Information Governance Alliance to the absence of NHS guidance on voicemail use.
Verbatim wording from the response “We will also alert the Information Governance Alliance (which is the authoritative source of advice and guidance about the rules on using and sharing information in health and care in England) to the absence of guidance for NHS staff on the use of voicemail.” Source location 2018-0073-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 Specific procedural advice on voicemail decisions and contents is outside the remit of general GMC guidance.
Verbatim wording from the response “Given the nature and remit of our guidance, we do not give further procedural advice on what specific steps doctors should take when weighing up whether to leave a voicemail message, or what its contents should be. However the guidance is clear that while confidentiality is an important and legal duty it is not absolute and the safety of patients must be taken into account. In line with the general approach in the guidance, a decision not to leave a message would need to be balanced against the harm (or lack of benefit) to the patient in delaying communication and perhaps further treatment as a consequence.” Source location 2018-0073-Response-by-General-Medical-Council
Open published response
14 Nov 2017 Rose Ball · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Pattern of diagnoses by telephone View source Failure to ensure clinical records reflect examinations actually performed View source Failure of NHS investigations to identify the telephone consultation issue View source Failure to record that consultations were by telephone 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
Rose Ball · 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
Rose Ball, aged 82, was admitted to hospital in the early hours of 8 December 2016 and died later that day following acute peritonitis from a perforated duodenum. The report raised concerns that GP consultations on 6 and 7 December were conducted by telephone but were not recorded as such, that an abdominal examination was recorded although it did not take place, and that there was a wider pattern of diagnosing conditions by telephone without safety-netting or plans for examination.
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 Pattern of diagnoses by telephone
Wider context from the report “1. ████████ failed to record that the consultations of 6 and 7 December were by telephone – and in fact recorded an abdominal examination that never took place.
2. I was troubled by ████████ evidence in court that he considered his only failing was in relation to record-keeping.
3. It is clear that ████████ conduct goes well beyond poor record-keeping. I have referred to a pattern of diagnoses by telephone by this practice . I hold records from January 2015 onwards only. It is possible that this pattern may be repeated earlier in this patient’s records – or perhaps in the records of other patients .
4. I invite you to consider the fitness to practice of ████████, in view of the findings of this inquest.
5. I strongly urge the recipients of this report to listen to the recording of this inquest. This can be supplied electronically (via Cryptshare) or on a CD.
The fact that a Regulation 28 report has been issued to the GMC should not be interpreted as a criticism of that organisation. This point has been made clearly in the case of R (Dr Siddiqui and Dr Paeprer-Rohricht) v Assistant Coroner for East London.
I have raised my concerns using Regulation 28 of the Coroners Investigations Regulations 2013 in view of the serious nature of the concerns I have, and in view of the fact that previous NHS investigations have already taken place and not brought the telephone consultation point to light. I consider this a matter of concern for wider public safety.
For the avoidance of doubt, whilst I would welcome replies from NHS England and the CQC to the issues I have raised, a formal response to this report is required only from the GMC.
” 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 clinical records reflect examinations actually performed
Wider context from the report “1. ████████ failed to record that the consultations of 6 and 7 December were by telephone – and in fact recorded an abdominal examination that never took place .
2. I was troubled by ████████ evidence in court that he considered his only failing was in relation to record-keeping.
3. It is clear that ████████ conduct goes well beyond poor record-keeping. I have referred to a pattern of diagnoses by telephone by this practice. I hold records from January 2015 onwards only. It is possible that this pattern may be repeated earlier in this patient’s records – or perhaps in the records of other patients.
4. I invite you to consider the fitness to practice of ████████, in view of the findings of this inquest.
5. I strongly urge the recipients of this report to listen to the recording of this inquest. This can be supplied electronically (via Cryptshare) or on a CD.
The fact that a Regulation 28 report has been issued to the GMC should not be interpreted as a criticism of that organisation. This point has been made clearly in the case of R (Dr Siddiqui and Dr Paeprer-Rohricht) v Assistant Coroner for East London.
I have raised my concerns using Regulation 28 of the Coroners Investigations Regulations 2013 in view of the serious nature of the concerns I have, and in view of the fact that previous NHS investigations have already taken place and not brought the telephone consultation point to light. I consider this a matter of concern for wider public safety.
For the avoidance of doubt, whilst I would welcome replies from NHS England and the CQC to the issues I have raised, a formal response to this report is required only from the GMC.
” 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 NHS investigations to identify the telephone consultation issue
Wider context from the report “1. ████████ failed to record that the consultations of 6 and 7 December were by telephone – and in fact recorded an abdominal examination that never took place.
2. I was troubled by ████████ evidence in court that he considered his only failing was in relation to record-keeping.
3. It is clear that ████████ conduct goes well beyond poor record-keeping. I have referred to a pattern of diagnoses by telephone by this practice. I hold records from January 2015 onwards only. It is possible that this pattern may be repeated earlier in this patient’s records – or perhaps in the records of other patients.
4. I invite you to consider the fitness to practice of ████████, in view of the findings of this inquest.
5. I strongly urge the recipients of this report to listen to the recording of this inquest. This can be supplied electronically (via Cryptshare) or on a CD.
The fact that a Regulation 28 report has been issued to the GMC should not be interpreted as a criticism of that organisation. This point has been made clearly in the case of R (Dr Siddiqui and Dr Paeprer-Rohricht) v Assistant Coroner for East London.
I have raised my concerns using Regulation 28 of the Coroners Investigations Regulations 2013 in view of the serious nature of the concerns I have, and in view of the fact that previous NHS investigations have already taken place and not brought the telephone consultation point to light . I consider this a matter of concern for wider public safety.
For the avoidance of doubt, whilst I would welcome replies from NHS England and the CQC to the issues I have raised, a formal response to this report is required only from the GMC.
” 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 that consultations were by telephone
Wider context from the report “1. ████████ failed to record that the consultations of 6 and 7 December were by telephone – and in fact recorded an abdominal examination that never took place.
2. I was troubled by ████████ evidence in court that he considered his only failing was in relation to record-keeping.
3. It is clear that ████████ conduct goes well beyond poor record-keeping. I have referred to a pattern of diagnoses by telephone by this practice. I hold records from January 2015 onwards only. It is possible that this pattern may be repeated earlier in this patient’s records – or perhaps in the records of other patients.
4. I invite you to consider the fitness to practice of ████████, in view of the findings of this inquest.
5. I strongly urge the recipients of this report to listen to the recording of this inquest. This can be supplied electronically (via Cryptshare) or on a CD.
The fact that a Regulation 28 report has been issued to the GMC should not be interpreted as a criticism of that organisation. This point has been made clearly in the case of R (Dr Siddiqui and Dr Paeprer-Rohricht) v Assistant Coroner for East London.
I have raised my concerns using Regulation 28 of the Coroners Investigations Regulations 2013 in view of the serious nature of the concerns I have, and in view of the fact that previous NHS investigations have already taken place and not brought the telephone consultation point to light. I consider this a matter of concern for wider public safety.
For the avoidance of doubt, whilst I would welcome replies from NHS England and the CQC to the issues I have raised, a formal response to this report is required only from the GMC.
” Open source report
1 Jun 2016 Rhi anne Anoushka Florence BARTON · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 7 Failure to accurately record routine observations, fluid balance and gastrointestinal losses View source Failure to make specific obstetric care plans for pregnancy and labour after bariatric surgery View source Failure to provide timely obstetric consultant supervision after emergency admission View source Lack of specific clinical guidance on obstetric care after bariatric surgery View source Failure to act on markedly abnormal urine glucose findings View source Delays in undertaking appropriate investigations for unexplained abdominal pain View source Failure to consider surgical causes of abdominal symptoms after bariatric surgery 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
Rhi anne Anoushka Florence BARTON · 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
Rhi anne Barton developed severe abdominal pain and vomiting at 35 weeks of pregnancy after previous bariatric surgery and was later found to have a small bowel obstruction. She aspirated during induction of anaesthesia before surgery, developed severe physiological compromise and died in the early hours of 13 February 2015. The principal concerns included delays in investigation, diagnosis and surgical management, lack of consultant supervision, inadequate documentation and fluid monitoring, and insufficient consideration of surgical causes associated with previous bariatric surgery.
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 accurately record routine observations, fluid balance and gastrointestinal losses
Wider context from the report “4. Evidence was presented of poor documentation of routine observations and an incomplete fluid balance chart . No accurate records were kept with regard to fluid intake and urine output . It was not possible to assess the amount, frequency and volume of the vomitus . There was no evidence of diarrhoea despite a diagnosis of gastroenteritis . A urine dipstick was undertaken which revealed 4+ of glucose but no action was undertaken with regard to the finding.
” 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 make specific obstetric care plans for pregnancy and labour after bariatric surgery
Wider context from the report “5. The obstetric consultant made no specific plans with regard to the obstetric care that Rhi anne would receive during pregnancy and labour despite knowing that she had undergone bariatric surgery . I also heard evidence that bariatric surgery was becoming increasingly common but the Royal College of Obstetrics and Gynaecology had not specifically addressed this issue in their guidance to practicing clinicians.
” 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 timely obstetric consultant supervision after emergency admission
Wider context from the report “1. Rhi anne’s named obstetric consultant was not informed of her emergency admission . Although there was a consultant obstetrician on the ward on the 11th February there was no request for Rhi anne to be seen and in any event it was not common practice for patients to be seen by another consultant. As such there was no obstetric consultant supervision of Rhi anne from the time of admission until shortly before her surgery; approximately 43 hours after admission .
” 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 specific clinical guidance on obstetric care after bariatric surgery
Wider context from the report “5. The obstetric consultant made no specific plans with regard to the obstetric care that Rhi anne would receive during pregnancy and labour despite knowing that she had undergone bariatric surgery. I also heard evidence that bariatric surgery was becoming increasingly common but the Royal College of Obstetrics and Gynaecology had not specifically addressed this issue in their guidance to practicing clinicians .
” 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 act on markedly abnormal urine glucose findings
Wider context from the report “4. Evidence was presented of poor documentation of routine observations and an incomplete fluid balance chart. No accurate records were kept with regard to fluid intake and urine output. It was not possible to assess the amount, frequency and volume of the vomitus. There was no evidence of diarrhoea despite a diagnosis of gastroenteritis. A urine dipstick was undertaken which revealed 4+ of glucose but no action was undertaken with regard to the finding .
” 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 undertaking appropriate investigations for unexplained abdominal pain
Wider context from the report “3. I also heard evidence that whilst the rarity of an omental band may make it difficult to diagnose there was still a responsibility to exclude other causes of abdominal pain in the absence of an obstetric cause , by undertaking appropriate investigations in a timely fashion .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to consider surgical causes of abdominal symptoms after bariatric surgery
Wider context from the report “2. No consideration was given to excluding a surgical cause of Rhi anne’s symptoms despite the history of sudden onset of upper abdominal pain in the knowledge that she had had bariatric surgery . I heard evidence that bariatric surgery can, not infrequently, result in an omental/internal hernia causing small bowel obstruction but that it was not widely understood and should be given greater recognition nationally as more women are becoming pregnant following bariatric surgery.
” Open source report
16 May 2016 Mr Critall · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 23 Minimal respiratory consultant documentation View source Outdated chest drain management protocol lacking complication actions View source Use of 6 f gauge pigtail catheters for pleural effusions without supporting evidence View source Excessive patient caseloads and unclear experience among senior resident medical staff View source Failure to document clinical examination View source Failure to complete consent detailing chest drain complications View source Failure to request repeat inflammatory markers View source Poor communication of the post-procedure care plan to ward staff View source Failure to use a WHO checklist for radiological interventions View source Proactive chest drain insertion without objective clinical evidence View source Absence of a documented management plan View source Failure to use real-time ultrasound guidance for chest drain insertion View source Failure to establish clinical necessity for chest drain insertion View source Lack of Acute or Basic Life Support training for the radiologist View source Reliance on emergency paramedic attendance to provide hospital care before transfer View source Insufficient nursing competence in resuscitation and chest drain management View source Lack of independent radiological indications for chest drain insertion View source Chest drain insertion decisions influenced by the day of the week View source Failure to radiologically confirm the position of a non-draining chest drain View source Failure to record observations before and after chest drain procedures View source Admission of acutely unwell patients without onsite HDU/ITU facilities View source Absence of operational protocols for hospital emergency situations View source Absence of HDU or ITU capability for hospital emergency situations View source See 20 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
Mr Critall · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Critall, an 80-year-old man, developed a haemothorax after insertion of a chest drain while being treated for pneumonia and died on 6 July 2014 after further deterioration and emergency treatment. The report raised concerns about the necessity and technique of the drain insertion, the failure to confirm its position, inadequate monitoring and resuscitation, and the hospital’s lack of appropriate emergency facilities and protocols. It also recorded that his family were not contacted after he became unwell or died.
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 Minimal respiratory consultant documentation
Wider context from the report “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission . There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist.
” 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 Outdated chest drain management protocol lacking complication actions
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose .
” 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 Use of 6 f gauge pigtail catheters for pleural effusions without supporting evidence
Wider context from the report “8. The use of a 6 f gauge pig tail catheter in the management of pleural effusions with or without an empyema was against both national guidelines and expert evidence heard at inquest and was unsupported by either international research or any recent local audits undertaken to justify their use in preference for larger small bore chest drains .
” 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 Excessive patient caseloads and unclear experience among senior resident medical staff
Wider context from the report “1. The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration. The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72 . This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of chest drain insertion for pneumonic pleural effusions, usually having to deal with malignant pleural effusions.
” 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 clinical examination
Wider context from the report “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist.
” 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 complete consent detailing chest drain complications
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications , radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” 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 request repeat inflammatory markers
Wider context from the report “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist.
” 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 Poor communication of the post-procedure care plan to ward staff
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” 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 use a WHO checklist for radiological interventions
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist , no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” 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 Proactive chest drain insertion without objective clinical evidence
Wider context from the report “9. The court heard evidence there was a ‘local’ proactive approach for the insertion of chest drains based on no objective evidence other than a belief that the very smallest catheters were safer and more comfortable and reduced referral for surgical management of an empyema. This view was against expert evidence at inquest and concern was raised that this approach inevitably led to an excess of chest drains being inserted unnecessarily particularly when BTS guidelines were not being routinely applied and/or no evidence of a developing or actual empyema.
” 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 Absence of a documented management plan
Wider context from the report “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place , no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist.
” 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 use real-time ultrasound guidance for chest drain insertion
Wider context from the report “5. Real time ultrasound visualisation was not used to guide the chest drain insertion against ‘best practice’ . I was led to believe ‘best practice’ was not commonly practiced at the Royal Surrey County Hospital and in many other hospitals nationally. I also heard evidence real time ultrasound visualisation would have assisted the insertion as the effusion was small and lay in an awkward position close to tethering of the lung to the chest wall (which was not documented in the hospital notes or radiologist’s statement but was clearly present on ultrasound pictures examined by ████████ and acknowledged to be present by the radiologist who undertook the chest drain insertion in oral testimony).
” 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 establish clinical necessity for chest drain insertion
Wider context from the report “3. The insertion of a chest drain on the 4th July was not supported by British Thoracic Society (BTS) guidelines and was attempted on a background of an improving clinical picture without repeat of relevant investigations (e.g. inflammatory markers) or evidence of a developing or actual empyema or a further medical review, by either the radiologist or responsible clinician, to confirm its necessity .
” 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 Acute or Basic Life Support training for the radiologist
Wider context from the report “10. The radiologist did not have Acute or Basic Life Support training as would be expected for all clinical hospital staff as part of mandatory training for NHS appointments.
” 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 Reliance on emergency paramedic attendance to provide hospital care before transfer
Wider context from the report “2. The absence of operational protocols and a HDU/ITU facility to manage emergency situations and a reliance on a 999 call for paramedics to provide care for a hospital who undertakes such procedures prior to transferring an unwell patient to an NHS hospital .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing competence in resuscitation and chest drain management
Wider context from the report “1. The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration. The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72. This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of chest drain insertion for pneumonic pleural effusions , usually having to deal with malignant pleural effusions.
” 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 independent radiological indications for chest drain insertion
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant , a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” 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 Chest drain insertion decisions influenced by the day of the week
Wider context from the report “4. I heard evidence that the insertion of a chest drain may pre-empt difficulties that may arise if Mr Critall deteriorated over the approaching weekend. This was contrary to expert evidence that chest drain insertion should only be considered as a necessity and should not be influenced by the day of the week .
” 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 radiologically confirm the position of a non-draining chest drain
Wider context from the report “6. The position of the non-draining (second attempt) chest drain was not radiologically confirmed, against expected practice, particularly as it was not draining . I heard exert evidence that this resulted in a delay in the recognition and prompt management of the haemothorax which contributed to Mr Critall’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record observations before and after chest drain procedures
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” 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 Admission of acutely unwell patients without onsite HDU/ITU facilities
Wider context from the report “1. The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration . The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72. This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of chest drain insertion for pneumonic pleural effusions, usually having to deal with malignant pleural effusions.
” 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 Absence of operational protocols for hospital emergency situations
Wider context from the report “2. The absence of operational protocols and a HDU/ITU facility to manage emergency situations and a reliance on a 999 call for paramedics to provide care for a hospital who undertakes such procedures prior to transferring an unwell patient to an NHS hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Absence of HDU or ITU capability for hospital emergency situations
Wider context from the report “2. The absence of operational protocols and a HDU/ITU facility to manage emergency situations and a reliance on a 999 call for paramedics to provide care for a hospital who undertakes such procedures prior to transferring an unwell patient to an NHS hospital.
” Open source report
29 Dec 2015 Imran DOUGLAS · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Lack of social worker knowledge of Transition Plans View source Failure to ensure YOT and YJB knowledge and expertise are considered in placements before completion of the Transition Plan View source Lack of accessible universal records throughout the offender pathway View source Disconnection between Looked After Child pathway planning and Transition Planning View source Failure to propose clinical interventions View source Failure to record clinical history and examination View source Failure of social workers to communicate directly with secure estate staff 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
Imran DOUGLAS · 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
Imran Douglas died by suicide on 13 November 2013, on the fifth day of his detention at HMP Belmarsh, after being sentenced to 18 years. The report identified concerns about transition and placement arrangements, communication and information-sharing between agencies, access to electronic records, and the adequacy of a medical assessment and response to suicide risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of social worker knowledge of Transition Plans
Wider context from the report “Evidence pointed to a disconnection between Looked After Child pathway planning and Transition Planning. A social worker said that the LAC plan was “potentially informative” but did not matter if it was not completed, but that now it is regarded as key and should be shared. One social worker said she did not know what a Transition Plan was . The current Head of Children's Social Care at LB Tower Hamlets said that staff pressures at the time had eased somewhat, but that under her leadership the interface with the secure estate was through the YJB and so social workers do not directly talk to the secure estate staff. This was despite the requirement for the two to work together in the Youth to Adult Transitions Framework. Given the lack of documented communications of the risks and concerns between YOT and Feltham in 2013, this evidence throws doubt on the reported improvements in training and changes in interagency communication have been put into operation since.
” 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 YOT and YJB knowledge and expertise are considered in placements before completion of the Transition Plan
Wider context from the report “I consider that there is an outstanding risk that, when a rising 18 enters the criminal justice system with insufficient time for the normal Transition Plan, and especially when staff are under pressure, that even with the changes in placements from courts that have been made, and the Joint National Protocol, the knowledge and expertise of the YOT and YJB may not be properly considered in a placement if the legal duty for placement has passed to the PMU before the Plan is complete .
” 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 accessible universal records throughout the offender pathway
Wider context from the report “The jury criticised the lack of access of HMP Belmarsh to the E Asset system and the fact that key documents from the Secure Training Centre were never accessed by the secure estate . The lack of a universal system of records throughout the offender’s pathway results in information on risk not being known to others and may contribute to 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 Disconnection between Looked After Child pathway planning and Transition Planning
Wider context from the report “Evidence pointed to a disconnection between Looked After Child pathway planning and Transition Planning . A social worker said that the LAC plan was “potentially informative” but did not matter if it was not completed, but that now it is regarded as key and should be shared. One social worker said she did not know what a Transition Plan was. The current Head of Children's Social Care at LB Tower Hamlets said that staff pressures at the time had eased somewhat, but that under her leadership the interface with the secure estate was through the YJB and so social workers do not directly talk to the secure estate staff. This was despite the requirement for the two to work together in the Youth to Adult Transitions Framework. Given the lack of documented communications of the risks and concerns between YOT and Feltham in 2013, this evidence throws doubt on the reported improvements in training and changes in interagency communication have been put into operation since.
” 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 propose clinical interventions
Wider context from the report “The GP did not record history or examination or propose any interventions despite being aware of the young age, long sentence and suicide warning form. The clinical review conducted as part of the Prison and Probation Ombudsman’s Report concluded that health care provision in HMP Belmarsh was below the standard expected.
” 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 history and examination
Wider context from the report “The GP did not record history or examination or propose any interventions despite being aware of the young age, long sentence and suicide warning form. The clinical review conducted as part of the Prison and Probation Ombudsman’s Report concluded that health care provision in HMP Belmarsh was below the standard expected.
” 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 social workers to communicate directly with secure estate staff
Wider context from the report “Evidence pointed to a disconnection between Looked After Child pathway planning and Transition Planning. A social worker said that the LAC plan was “potentially informative” but did not matter if it was not completed, but that now it is regarded as key and should be shared. One social worker said she did not know what a Transition Plan was. The current Head of Children's Social Care at LB Tower Hamlets said that staff pressures at the time had eased somewhat, but that under her leadership the interface with the secure estate was through the YJB and so social workers do not directly talk to the secure estate staff . This was despite the requirement for the two to work together in the Youth to Adult Transitions Framework. Given the lack of documented communications of the risks and concerns between YOT and Feltham in 2013, this evidence throws doubt on the reported improvements in training and changes in interagency communication have been put into operation since.
” Open source report
2 Nov 2015 Steven David Jackson · Prevention of Future Deaths report Essex
View report summary
Concerns raised 5 Lack of up-to-date knowledge among general practitioners about epiglottitis in adults View source Lack of effective training of ambulance staff on when to convey a patient to hospital View source Failure to learn from prior events View source Lack of effective training of ambulance staff in use of the sepsis screening tool View source Ineffective use of the sepsis screening tool by ambulance staff 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
Steven David Jackson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Steven David Jackson attended Southend Hospital on 5 March 2014, was later taken there by ambulance after collapsing, and died at 14:26. The inquest recorded acute epiglottitis as the cause of death and identified very serious failings in the care provided by ambulance staff. Concerns also included an out-of-hours general practitioner’s apparently outdated knowledge of epiglottitis in adults.
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 up-to-date knowledge among general practitioners about epiglottitis in adults
Wider context from the report “1. The general practitioner, employed by the out of hours service IC24, seemed to have out of date knowledge of the incidence of epiglottitis generally . He seemed to be under the impression that it was still very much a condition found among children and would not be expected in an adult such as Mr Jackson.
” 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 training of ambulance staff on when to convey a patient to hospital
Wider context from the report “1. The paramedic who attended at around 10:00am gave evidence which indicated that she did not seem to have learned from the events in March 2014.
2. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively.
3. There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as to when it is appropriate to convey a patient to hospital .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from prior events
Wider context from the report “1. The paramedic who attended at around 10:00am gave evidence which indicated that she did not seem to have learned from the events in March 2014 .
2. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively.
3. There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as to when it is appropriate to convey a patient to hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of effective training of ambulance staff in use of the sepsis screening tool
Wider context from the report “1. The paramedic who attended at around 10:00am gave evidence which indicated that she did not seem to have learned from the events in March 2014.
2. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively.
3. There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as to when it is appropriate to convey a patient to hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Ineffective use of the sepsis screening tool by ambulance staff
Wider context from the report “1. The paramedic who attended at around 10:00am gave evidence which indicated that she did not seem to have learned from the events in March 2014.
2. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively .
3. There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as to when it is appropriate to convey a patient to hospital.
” Open source report
22 Oct 2015 Harry George Mellor · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Lack of a reliable system to identify children de-registered from a General Practice View source Lack of a legal requirement to register or re-register children with a General Practitioner View source Failure to ensure a new General Practitioner is identified and notified before a child is de-registered View source Failure to directly inform paediatric and physiotherapy services of a child's de-registration 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
Harry George Mellor · 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 George Mellor, a child with chronic health needs, collapsed unexpectedly on 28 October 2014 and died shortly after arriving at the emergency department. The inquest recorded that he had died from pyelonephritis. Concerns included the lack of a reliable system to identify when a child was de-registered from a GP, potential safeguarding risks when no new GP had been identified, and the paediatric and physiotherapy teams not being informed of the de-registration.
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 a reliable system to identify children de-registered from a General Practice
Wider context from the report “2. There is no reliable system in place to identify when a child has been de-registered from a General 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 a legal requirement to register or re-register children with a General Practitioner
Wider context from the report “1. There is no legal requirement to register or re-register a child with a General Practitioner
” 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 a new General Practitioner is identified and notified before a child is de-registered
Wider context from the report “3. There are potential safeguarding concerns if a General Practitioner can de-register a child , particularly a child with chronic health needs, before a new General Practitioner has been identified and notified of the proposed de-registration
” 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 directly inform paediatric and physiotherapy services of a child's de-registration
Wider context from the report “4. The paediatric team and physiotherapy services were not directly informed that Harry was going to be de-registered or had been de-registered
” 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 professional guidance requiring doctors to support vulnerable children, share information, act on safeguarding concerns, and contribute to safe care handovers.
Verbatim wording from the response “We publish guidance setting out the professional values and standards of practice expected of all doctors working in the UK - our core guidance is Good medical practice which is supported by a range of explanatory guidance on topics such as patient confidentiality, consent to treatment, child protection and other issues in healthcare practice. We do not have a direct role in the design and operation of healthcare services and the systems for managing patients’ clinical care, although the standards in our guidance will touch on doctors responsibilities for ensuring” Source location GMC-Response
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for national clinical-monitoring systems, administrative removals and records transfers; NHS systems changes should be pursued with relevant organisations.
Verbatim wording from the response “The design and management of national systems of clinical monitoring and quality in England are the responsibility of NHS England. NHS England is also the primary care organisation responsible for receiving administrative removals from GP practices and the recipient of any requests for records to be transferred once a patient has registered with a new practice. NHS England is currently developing a system to improve the protection of children who have previously been identified as vulnerable by social services, the Child Protection – Information Sharing (CP-IS) project. More information about NHS systems, including the CP-IS project are available from NHS England, and information about how these services work at the local level can be obtained from the GP contracting team at NHS England.” Source location GMC-Response
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 Designing and operating healthcare services and clinical-care management systems are outside the respondent’s direct role.
Verbatim wording from the response “We publish guidance setting out the professional values and standards of practice expected of all doctors working in the UK - our core guidance is Good medical practice which is supported by a range of explanatory guidance on topics such as patient confidentiality, consent to treatment, child protection and other issues in healthcare practice. We do not have a direct role in the design and operation of healthcare services and the systems for managing patients’ clinical care, although the standards in our guidance will touch on doctors responsibilities for ensuring” Source location GMC-Response
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 respondent lacks power to require parents or guardians to register children with GPs or notify GPs when leaving practice areas.
Verbatim wording from the response “Our guidance sets out a number of duties on doctors which are relevant to Harry’s case, as they concern responsibilities for managing or participating in organisational systems set up to prevent and reduce harm to patients, and responsibilities to work with child patients and their parents or guardians in ways that ensure the health needs of children are met and action is taken on child protection concerns. We do not have any powers to create obligations for parents or guardians such as requiring them to register their children with a GP or to notify their GP when leaving the practice area.” Source location GMC-Response
Open published response
22 Apr 2015 Laurence Boyens · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 12 Failure to recognise appropriate indications for Naloxone administration View source Failure to communicate and define reporting parameters for pre-administration blood-pressure readings View source Failure to record respiratory rates when monitoring controlled-drug patients View source Failure to cancel discontinued medication prescriptions in the computerised record View source Failure to record blood-pressure readings promptly in medical records View source Failure to identify and act on drowsiness before controlled-drug administration View source Failure to stop medicines when Methadone toxicity is considered View source Failure to review blood-pressure trends before controlled-drug administration View source Failure to suspend controlled drugs and escalate low blood pressure View source Lack of defined criteria and recording requirements for lowering blood pressure View source Prescribing multiple medicines without a sufficiently complete clinical assessment and medication history View source Failure to assess drug interactions and cumulative effects before prescribing View source See 9 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
Laurence Boyens · 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
Laurence Boyens died in prison on 15 November 2012 from Methadone, Tramadol and Diazepam intoxication. The jury identified concerns about the combination and interaction of prescribed drugs, failures to monitor intoxication symptoms and blood pressure, and failures to suspend or withhold Methadone and Tramadol when signs of toxicity were present.
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 recognise appropriate indications for Naloxone administration
Wider context from the report “4. ████████
████████ was represented at the inquest and the following evidence gave rise to concerns:
• He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison.
• When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone, both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam.
• He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing.
• He said that he did not know whether he should stop Methadone if the BP was low.
• Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy.
• At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered.
• At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered.
• He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so . ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives.
” 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 communicate and define reporting parameters for pre-administration blood-pressure readings
Wider context from the report “1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug.
• Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading
• The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP
• The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all
• A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th.
• One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP.
• One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor.
• The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur.
• The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays.
• In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies.
• No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”.
• At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication, and he was given Methadone and Tramadol.
• On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day review.
” 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 respiratory rates when monitoring controlled-drug patients
Wider context from the report “3. Nurse ████████ was called during the course of the inquest, and although given the opportunity, did not have legal representation in the proceedings.
The evidence from Nurse ████████ herself that caused concern about risks to future patients included:
• She did not record a BP at 18.35 on 10th, or at 09.25 on 11th, prior to administration of Methadone.
• She did not notice a BP of 93/68 recorded on “System One” at 15.27, before she administered Methadone at 17.50 on 11th.
• She expected the health care assistant to inform her of an abnormal blood pressure, but has not set any parameters, prior to Methadone
• She never looked at previous blood pressures prior to administering Methadone.
• She never makes respiratory rate recordings in monitoring patients on controlled drugs
• If she had seen the blood pressure of 134/113 that was recorded at 09.21 on 12th November, she would not do anything different.
• Given that her drug administration clinics were very busy (60 people per session), she was asked whether it would make any difference to what she did, if she saw half as many patients, but she said she would still not look at the blood pressures.
• Asked if she had changed her practice in any way since the incident, she said that she had 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 cancel discontinued medication prescriptions in the computerised record
Wider context from the report “4. ████████
████████ was represented at the inquest and the following evidence gave rise to concerns:
• He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison.
• When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone, both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam.
• He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing.
• He said that he did not know whether he should stop Methadone if the BP was low.
• Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy.
• At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered.
• At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered .
• He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so. ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives.
” 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 blood-pressure readings promptly in medical records
Wider context from the report “1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug.
• Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading
• The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP
• The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all
• A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th.
• One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP.
• One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor.
• The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur.
• The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays.
• In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies.
• No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”.
• At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication, and he was given Methadone and Tramadol.
• On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day review.
” 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 identify and act on drowsiness before controlled-drug administration
Wider context from the report “1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug.
• Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading
• The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP
• The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all
• A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th.
• One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP.
• One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor.
• The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur.
• The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays.
• In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies.
• No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”.
• At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication , and he was given Methadone and Tramadol.
• On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day review.
” 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 stop medicines when Methadone toxicity is considered
Wider context from the report “4. ████████
████████ was represented at the inquest and the following evidence gave rise to concerns:
• He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison.
• When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone, both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam.
• He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing.
• He said that he did not know whether he should stop Methadone if the BP was low.
• Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy.
• At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered .
• At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered.
• He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so. ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives.
” 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 review blood-pressure trends before controlled-drug administration
Wider context from the report “1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug.
• Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading
• The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP
• The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all
• A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th.
• One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP.
• One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor.
• The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur.
• The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays.
• In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies.
• No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”.
• At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication, and he was given Methadone and Tramadol.
• On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day review.
” 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 suspend controlled drugs and escalate low blood pressure
Wider context from the report “1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug.
• Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading
• The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP
• The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all
• A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th.
• One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP.
• One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor.
• The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur .
• The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays.
• In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies.
• No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”.
• At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication, and he was given Methadone and Tramadol.
• On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day review.
” 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 defined criteria and recording requirements for lowering blood pressure
Wider context from the report “1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug.
• Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading
• The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP
• The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all
• A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th.
• One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP.
• One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor.
• The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur.
• The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays.
• In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies .
• No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”.
• At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication, and he was given Methadone and Tramadol.
• On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day review.
” 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 multiple medicines without a sufficiently complete clinical assessment and medication history
Wider context from the report “4. ████████
████████ was represented at the inquest and the following evidence gave rise to concerns:
• He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him , although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison .
• When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone, both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam.
• He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing.
• He said that he did not know whether he should stop Methadone if the BP was low.
• Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy.
• At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered.
• At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered.
• He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so. ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives.
” 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 drug interactions and cumulative effects before prescribing
Wider context from the report “4. ████████
████████ was represented at the inquest and the following evidence gave rise to concerns:
• He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison.
• When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone , both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam .
• He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing.
• He said that he did not know whether he should stop Methadone if the BP was low.
• Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy.
• At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered.
• At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered.
• He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so. ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives.
” Open source report
14 Aug 2014 Thomas Warren · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Lack of regulatory monitoring and review of incomplete remediation referrals before subsequent locum employment View source Failure to secure complete employment histories, references and fitness to practise information for long-term locum doctors View source Unavailability of GMC-held fitness to practise and NCAS referral information to subsequent enquirers View source Failure to place provisional registration conditions when an NCAS assessment is at risk of remaining incomplete View source Lack of clarity over responsibility for enquiring into previous fitness to practise concerns and NCAS referrals when recruiting short-notice locum doctors 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
Thomas Warren · 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
Thomas Warren, a child with cerebral palsy, died after receiving a 25 microgram fentanyl patch for pain and subsequently developing symptoms before suffering a cardiac arrest. The report identified concerns about prescribing an opiate to an opiate-naïve child without hospital admission, missed opportunities to stop dispensing the drug and provide parents with adequate monitoring information, and gaps in checks on the fitness to practise of a locum doctor.
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 regulatory monitoring and review of incomplete remediation referrals before subsequent locum employment
Wider context from the report “(4) There did not appear to be any regulatory mechanism for monitoring or reviewing cases where the doctor no longer works for the Trust where a remediation referral was made and NCAS (or other body) assessment is not completed, before subsequent locum employment. Revalidation requirements might not be an effective mechanism for employment of short notice locum vacancies.
” 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 secure complete employment histories, references and fitness to practise information for long-term locum doctors
Wider context from the report “(2) There are particular difficulties with securing a complete sequence of employment and the associated references and confirmation about concerns for fitness to practice of long term locum doctors who may have gaps between jobs or worked abroad . Thus serious concerns about practice may have existed but not come to notice of the Agency or prospective employing NHS Trust .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of GMC-held fitness to practise and NCAS referral information to subsequent enquirers
Wider context from the report “(3) Crucial information was held by the GMC about concerns about this doctor’s fitness to practice, including his referral to NCAS. This information was not available to those enquiring about his fitness to practice at a subsequent time. Nor was any provisional condition placed on his registration, having learnt that he was leaving the NHS so that the NCAS assessment was at risk of being in abeyance.
” 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 place provisional registration conditions when an NCAS assessment is at risk of remaining incomplete
Wider context from the report “(3) Crucial information was held by the GMC about concerns about this doctor’s fitness to practice, including his referral to NCAS. This information was not available to those enquiring about his fitness to practice at a subsequent time. Nor was any provisional condition placed on his registration, having learnt that he was leaving the NHS so that the NCAS assessment was at risk of being in abeyance.
” 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 over responsibility for enquiring into previous fitness to practise concerns and NCAS referrals when recruiting short-notice locum doctors
Wider context from the report “(1) There does not appear to be clarity as to who or which organization should enquire into previous fitness to practice concerns and referrals to NCAS (or successor organization) which have not led to restrictions or conditions of registration by the GMC when locum doctors are being recruited by an Agency at short notice by prospective NHS Trusts. In this case it appears that neither the Recruitment Agency nor Trust nor consultant asked the doctor before his employment began.
” Open source report
1 May 2014 Elizabeth Jayne Cooper · Prevention of Future Deaths report Cumbria (South & East)
View report summary
Concerns raised 4 Unavailability of an information leaflet for patients on the fatal consequences of not seeking medical assistance View source Unclear advice on precautions for persons with the genetic condition during air and long-distance travel View source Unavailability of an information leaflet for family members on Factor V Leiden Mutation risks and available options View source Lack of a clear pathway for passing condition information to family members 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
Elizabeth Jayne Cooper · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Elizabeth Jayne Cooper had Factor V Leiden mutation and died after a holiday involving air travel; the inquest recorded pulmonary thromboembolism and deep vein thrombosis, with a conclusion of natural causes. The principal concerns were conflicting or unclear advice about precautions for air and long-distance travel, the lack of a clear pathway for informing family members, and the absence of information leaflets about the risks and consequences of untreated DVT and Factor V Leiden mutation.
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 an information leaflet for patients on the fatal consequences of not seeking medical assistance
Wider context from the report “(3) No information leaflet
(a) was available to Elizabeth concerning the fatal consequences of not seeking medical assistance;
(b) was available to be given to members of Elizabeth’s family to inform them of the risks involved in Factor V Leiden Mutation and the options open to them.
” 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 advice on precautions for persons with the genetic condition during air and long-distance travel
Wider context from the report “(1) Advice on precautions to be taken for those persons with the genetic condition is unclear especially concerning air and long distance travel.
” 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 an information leaflet for family members on Factor V Leiden Mutation risks and available options
Wider context from the report “(3) No information leaflet
(a) was available to Elizabeth concerning the fatal consequences of not seeking medical assistance;
(b) was available to be given to members of Elizabeth’s family to inform them of the risks involved in Factor V Leiden Mutation and the options open to them.
” 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 pathway for passing condition information to family members
Wider context from the report “(2) There seems no clear pathway for information concerning the condition to be passed to members of the family of the patient for them to assess their own position.
” Open source report
1 Apr 2014 Oliver George Hiscutt · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Lack of mandatory formal paediatric training for GPs 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
Oliver George Hiscutt · 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
Oliver George Hiscutt developed a Group A beta-haemolytic streptococcal infection with a retropharyngeal abscess, followed by catastrophic haemorrhage and cardiac arrests; he died on 7 October 2012. The report raised concern that formal paediatric or child-health training is not mandatory for GPs and that exposure to acute paediatrics during GP training is limited.
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 mandatory formal paediatric training for GPs
Wider context from the report “Currently it is not mandatory for GPs to undertake formal paediatric / child health training. Facing the Future (2011) states that there are currently 10 000 GP trainees in the country and less than 25% of them will undertake any paediatric placement during their training. GP trainees who do undertake a paediatric placement during their training gain a range of educational benefits such as the development of skills in spotting the sick child, specialist management of children with long term conditions and multi disciplinary team working.
The Royal College of General Practitioners and the Royal College of Paediatrics and Child Health strongly support all GPs having exposure to acute paediatrics as part of their vocational training. Offering every GP trainee a hospital post in paediatrics within the current 3 year specialty training programme is undeliverable. The Royal College of General Practitioners makes the case that there should be an enhanced 4 year programme of GP training and that all GPs should undertake specialist led paediatric training. Specialist led paediatric training will ensure that future GPs have the skills and experience they need to assess and respond effectively and safely to sick children, to better co-ordinate the care of children with long term conditions and to safeguard those at risk.
” Open source report
13 Feb 2014 Professor John Elfed Davies · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 6 Failure to provide information about relevant support agencies to clinicians subject to investigative processes View source Failure to recognise adverse psychological effects in clinicians subject to investigative processes View source Lack of psychological support for clinicians subject to investigative processes View source Failure to facilitate appropriate on-ward referral for clinicians subject to investigative processes View source Failure to assess and identify suicidal or other self-harming behaviour in clinicians subject to investigative processes View source Failure to use appropriate language and tone in written communications with clinicians subject to investigative processes 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
Professor John Elfed Davies · 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
Professor John Elfed Davies, aged 71, was found deceased in his hotel room on 10 June 2013 with self-inflicted incised wounds to his neck and multiple stab wounds to his chest. The inquest concluded that he took his own life, and a note indicated that GMC proceedings were playing on his mind. The principal concern was that doctors undergoing GMC investigations may experience unrecognised and unsupported adverse psychological effects, including suicidal or other self-harming behaviour.
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 information about relevant support agencies to clinicians subject to investigative processes
Wider context from the report “This is the second death of a doctor that has come before me over the last 2 years where a GMC investigation into the doctor’s practise has been found to play a part.
I am concerned that clinicians who are subject to such investigative processes are suffering adverse psychological effects which may be unrecognised and unsupported.
Consideration should be given to the language and tone of written communications, the provision of information about relevant support agencies , and the assessment and identification of suicidal or other self harming behaviour by the relevant body and the facilitation of appropriate on-ward referral.
” 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 recognise adverse psychological effects in clinicians subject to investigative processes
Wider context from the report “This is the second death of a doctor that has come before me over the last 2 years where a GMC investigation into the doctor’s practise has been found to play a part.
I am concerned that clinicians who are subject to such investigative processes are suffering adverse psychological effects which may be unrecognised and unsupported.
Consideration should be given to the language and tone of written communications, the provision of information about relevant support agencies, and the assessment and identification of suicidal or other self harming behaviour by the relevant body and the facilitation of appropriate on-ward referral.
” 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 psychological support for clinicians subject to investigative processes
Wider context from the report “This is the second death of a doctor that has come before me over the last 2 years where a GMC investigation into the doctor’s practise has been found to play a part.
I am concerned that clinicians who are subject to such investigative processes are suffering adverse psychological effects which may be unrecognised and unsupported .
Consideration should be given to the language and tone of written communications, the provision of information about relevant support agencies, and the assessment and identification of suicidal or other self harming behaviour by the relevant body and the facilitation of appropriate on-ward referral.
” 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 facilitate appropriate on-ward referral for clinicians subject to investigative processes
Wider context from the report “This is the second death of a doctor that has come before me over the last 2 years where a GMC investigation into the doctor’s practise has been found to play a part.
I am concerned that clinicians who are subject to such investigative processes are suffering adverse psychological effects which may be unrecognised and unsupported.
Consideration should be given to the language and tone of written communications, the provision of information about relevant support agencies, and the assessment and identification of suicidal or other self harming behaviour by the relevant body and the facilitation of appropriate on-ward referral .
” 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 identify suicidal or other self-harming behaviour in clinicians subject to investigative processes
Wider context from the report “This is the second death of a doctor that has come before me over the last 2 years where a GMC investigation into the doctor’s practise has been found to play a part.
I am concerned that clinicians who are subject to such investigative processes are suffering adverse psychological effects which may be unrecognised and unsupported.
Consideration should be given to the language and tone of written communications, the provision of information about relevant support agencies, and the assessment and identification of suicidal or other self harming behaviour by the relevant body and the facilitation of appropriate on-ward referral.
” 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 use appropriate language and tone in written communications with clinicians subject to investigative processes
Wider context from the report “This is the second death of a doctor that has come before me over the last 2 years where a GMC investigation into the doctor’s practise has been found to play a part.
I am concerned that clinicians who are subject to such investigative processes are suffering adverse psychological effects which may be unrecognised and unsupported.
Consideration should be given to the language and tone of written communications , the provision of information about relevant support agencies, and the assessment and identification of suicidal or other self harming behaviour by the relevant body and the facilitation of appropriate on-ward referral.
” Open source report
10 Jan 2014 Pauline Meredith · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 5 Lack of a formal medication review process for long-term medication prescribing View source Failure to listen to family concerns about changed patient behaviour View source Lack of team meetings to discuss challenging patients View source Failure to safely assess morphine prescribing alongside high-dose painkillers and alcohol dependence View source Lack of a timely proactive approach to involving community mental health services 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
Pauline Meredith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Pauline Meredith, aged 42, was found dead in her flat on 30 August 2013. Her death was attributed to mixed drug toxicity, including a fatal level of morphine, excessive levels of tramadol and propranolol, and alcohol. Concerns included the amount and review of prescribed medication, the addition of morphine alongside existing medication and alcohol dependence, the response to family concerns, the absence of team meetings, and delays in involving community 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 Lack of a formal medication review process for long-term medication prescribing
Wider context from the report “(1) The amount of medication prescribed to the deceased over many years with no formal medication review process .
” 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 listen to family concerns about changed patient behaviour
Wider context from the report “(3) The family’s perceived reluctance by the GP to listen to the concerns expressed by them with regards to the changed behaviour of the patient following the addition of morphine .
” 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 team meetings to discuss challenging patients
Wider context from the report “(4) The lack of any team meetings with colleagues affording an opportunity to discuss challenging patients with colleagues .
” 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 safely assess morphine prescribing alongside high-dose painkillers and alcohol dependence
Wider context from the report “(2) The more recent addition of morphine to the prescription for a patient already on a high dose of pain killers and with alcohol dependence
” 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 timely proactive approach to involving community mental health services
Wider context from the report “(5) The lack of a more timely proactive approach with regards to involving community mental health services .
” Open source report
Concerns raised 3 Failure to correctly diagnose patients' conditions View source Failure to provide truthful information about seeking clinical second opinions View source Continued practice by a GP whose fitness to practice is in doubt View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kate Louise PIERCE · 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
Kate Louise PIERCE died on 14 March 2013, aged 7, following complications associated with meningitis, including acquired cerebral palsy, epilepsy and chronic lung disease. The report raised concerns about the handling of her diagnosis at Wrexham Maelor Hospital and whether a doctor misled her parents about obtaining a second opinion. It also raised concerns about that doctor's fitness to practise and continued work as a GP, identifying a risk of future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly diagnose patients' conditions
Wider context from the report “On the 29th of March 2006 Kate was taken into the Wrexham Maelor Hospital where she was examined by a Dr ████████. It appears from the evidence available that he failed to deal correctly with the diagnosis of Kate's condition and furthermore there is a belief that he may have misled the parents of Kate by indicating that he had sought a second opinion from a colleague before discharging her when this was not in fact the case.
I understand that enquiries were made previously by the GMC following a complaint against Dr ████████ but that no action has been taken due to legal action by the Dr in view of the elapse of a relevant time limit.
In the course of my current investigation following Kate’s death, a statement has been obtained from a witness namely Dr ████████ and a copy of this is annexed hereto. My view is that this statement casts doubt on Dr ████████ fitness to practice and this is of grave concern as my understanding is that he currently continues to practice as a GP within my Corner Area.
In view of this I consider that there is a 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 provide truthful information about seeking clinical second opinions
Wider context from the report “On the 29th of March 2006 Kate was taken into the Wrexham Maelor Hospital where she was examined by a Dr ████████. It appears from the evidence available that he failed to deal correctly with the diagnosis of Kate's condition and furthermore there is a belief that he may have misled the parents of Kate by indicating that he had sought a second opinion from a colleague before discharging her when this was not in fact the case .
I understand that enquiries were made previously by the GMC following a complaint against Dr ████████ but that no action has been taken due to legal action by the Dr in view of the elapse of a relevant time limit.
In the course of my current investigation following Kate’s death, a statement has been obtained from a witness namely Dr ████████ and a copy of this is annexed hereto. My view is that this statement casts doubt on Dr ████████ fitness to practice and this is of grave concern as my understanding is that he currently continues to practice as a GP within my Corner Area.
In view of this I consider that there is a 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 Continued practice by a GP whose fitness to practice is in doubt
Wider context from the report “On the 29th of March 2006 Kate was taken into the Wrexham Maelor Hospital where she was examined by a Dr ████████. It appears from the evidence available that he failed to deal correctly with the diagnosis of Kate's condition and furthermore there is a belief that he may have misled the parents of Kate by indicating that he had sought a second opinion from a colleague before discharging her when this was not in fact the case.
I understand that enquiries were made previously by the GMC following a complaint against Dr ████████ but that no action has been taken due to legal action by the Dr in view of the elapse of a relevant time limit.
In the course of my current investigation following Kate’s death, a statement has been obtained from a witness namely Dr ████████ and a copy of this is annexed hereto. My view is that this statement casts doubt on Dr ████████ fitness to practice and this is of grave concern as my understanding is that he currently continues to practice as a GP within my Corner Area .
In view of this I consider that there is a risk of future deaths.
” 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 Responsible Officer oversight, complaint reporting and periodic revalidation were considered sufficient to address concerns about current fitness to practise.
Verbatim wording from the response “In terms of Dr ████████ current fitness to practise, we have not received any further complaints about Dr ████████ since 2007. Additionally, as part of the process of revalidation of a doctor’s licence to practise, doctors must have a Responsible Officer whose statutory duties include reporting concerns to us, if they call into question a doctor’s current fitness to practise. Our Employer Liaison Advisor who is a senior member” Source location 2013-0363-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 five-year statutory rule and unsuccessful exceptional-circumstances test prevented further investigation of the historical events and audit.
Verbatim wording from the response “We considered the complaint by Mr ████████ in accordance with our statutory framework and initially decided to investigate the case although the events at that time were more than five years old. Our statutory rules preclude us from investigating events that are more than five years old unless it is in the public interest in the exceptional circumstances to do so.” Source location 2013-0363-Response-by-General-Medical-Council
Open published response
23 Oct 2013 Jacqueline Allwood · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Failure of registration, assessment and referral documentation and consultation records to facilitate early diagnosis of DVT and low-threshold referral to A&E View source Failure to make changes to reduce risks of harm to patients View source Lack of assurance that the consulting GP understands and accepts normative standards of practice for history and examination 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
Jacqueline Allwood · 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
Jacqueline Allwood attended a GP with several days of calf pain and concern about a family history of thrombosis. She was not referred to hospital to exclude DVT and later died from pulmonary thromboembolism secondary to DVT. Concerns included whether registration, assessment and referral processes supported early diagnosis and referral, and whether the consulting GP understood and followed appropriate standards for history-taking and examination.
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 of registration, assessment and referral documentation and consultation records to facilitate early diagnosis of DVT and low-threshold referral to A&E
Wider context from the report “(1) The registration, assessment and referral forms and consultation records of and between the Urgent Care Centre and Cator Medical Practice may not facilitate the early diagnosis of DVT and the need for a low threshold of referral to A&E.
” 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 make changes to reduce risks of harm to patients
Wider context from the report “(2). Taking as a whole the evidence of the consulting GP, Dr Adlakha, it cannot be said that the public can be assured that he understands and accepts normative standards of practice with respect to history and examination and that he has made or will make changes in order to reduce risks of harm to patients .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Medical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of assurance that the consulting GP understands and accepts normative standards of practice for history and examination
Wider context from the report “(2). Taking as a whole the evidence of the consulting GP, Dr Adlakha, it cannot be said that the public can be assured that he understands and accepts normative standards of practice with respect to history and examination and that he has made or will make changes in order to reduce risks of harm to patients.
” 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