30 Dec 2019 Maureen Waterfall · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Lack of a national protocol for timely anticoagulant antidote administration View source Lack of a clear target time for anticoagulant antidote administration View source Lack of national standard guidance for storage of anticoagulant antidote supplies View source Failure to share anticoagulant reversal risks with non-tertiary centres View source Unavailability of anticoagulant antidote supplies at the resuscitation unit View source Absence of a currently licensed antidote for Edoxaban View source Limited ability to monitor the effectiveness of anticoagulant antidotes View source See 4 more concerns
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Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Maureen Waterfall · 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
Maureen Waterfall fell at home on 12 July 2019 while taking the anticoagulant Edoxaban and sustained a head injury that led to a subdural haematoma. She died at Willow Wood Hospice on 26 July 2019. Concerns included the lack of a licensed specific antidote for Edoxaban, uncertainty about treatment effectiveness and timing, the absence of national guidance, and the storage of antidote supplies away from the resuscitation unit.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Lack of a national protocol for timely anticoagulant antidote administration
Wider context from the report “2. The inquest was told that head injury patients who are prescribed Exodaban are at greater risk of continued bleeding to the brain than other patients as the absence of a specific antidote makes the reversal of the anticoagulant medication less certain. As with other newer anticoagulant drugs, there is little ability to monitor the effectiveness of the antidote. It was unclear if that understanding had been shared widely amongst non-tertiary centres to assist them in managing such patients.
The inquest was told that, at SRFT which is a tertiary centre for neuro surgery/ neurology they have taken steps to set a target for the use of anticoagulant antidote drugs at 90 minutes from presentation. It was unclear if this target was feeding into development of a national protocol . It was unclear how in the absence of national guidance that information was being shared with DGHs which rely on tertiary centres for expertise. At TGH there was no clear target time for the administration of anti-coagulations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear target time for anticoagulant antidote administration
Wider context from the report “2. The inquest was told that head injury patients who are prescribed Exodaban are at greater risk of continued bleeding to the brain than other patients as the absence of a specific antidote makes the reversal of the anticoagulant medication less certain. As with other newer anticoagulant drugs, there is little ability to monitor the effectiveness of the antidote. It was unclear if that understanding had been shared widely amongst non-tertiary centres to assist them in managing such patients.
The inquest was told that, at SRFT which is a tertiary centre for neuro surgery/ neurology they have taken steps to set a target for the use of anticoagulant antidote drugs at 90 minutes from presentation. It was unclear if this target was feeding into development of a national protocol. It was unclear how in the absence of national guidance that information was being shared with DGHs which rely on tertiary centres for expertise. At TGH there was no clear target time for the administration of anti-coagulations .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Lack of national standard guidance for storage of anticoagulant antidote supplies
Wider context from the report “3. I heard that there is no national standard guidance about the storage of supplies of anticoagulant antidote drugs . As a result, as in this case at Tameside General Hospital Accident and Emergency Department they were not kept at the resuscitation unit, but rather they were kept in the haematology department
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to share anticoagulant reversal risks with non-tertiary centres
Wider context from the report “2. The inquest was told that head injury patients who are prescribed Exodaban are at greater risk of continued bleeding to the brain than other patients as the absence of a specific antidote makes the reversal of the anticoagulant medication less certain. As with other newer anticoagulant drugs, there is little ability to monitor the effectiveness of the antidote. It was unclear if that understanding had been shared widely amongst non-tertiary centres to assist them in managing such patients.
The inquest was told that, at SRFT which is a tertiary centre for neuro surgery/ neurology they have taken steps to set a target for the use of anticoagulant antidote drugs at 90 minutes from presentation. It was unclear if this target was feeding into development of a national protocol. It was unclear how in the absence of national guidance that information was being shared with DGHs which rely on tertiary centres for expertise. At TGH there was no clear target time for the administration of anti-coagulations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Unavailability of anticoagulant antidote supplies at the resuscitation unit
Wider context from the report “3. I heard that there is no national standard guidance about the storage of supplies of anticoagulant antidote drugs. As a result, as in this case at Tameside General Hospital Accident and Emergency Department they were not kept at the resuscitation unit, but rather they were kept in the haematology department
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Absence of a currently licensed antidote for Edoxaban
Wider context from the report “1. I heard evidence from ████████ Clinical Director of Neurosciences at Salford Royal Hospital. He told me that Edoxaban was one of the new anticoagulant drugs, but of those with which he is familiar, it is differentiated by the fact that there is no currently licensed antidote . He is aware of clinical trials being undertaken of such an antidote.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Limited ability to monitor the effectiveness of anticoagulant antidotes
Wider context from the report “2. The inquest was told that head injury patients who are prescribed Exodaban are at greater risk of continued bleeding to the brain than other patients as the absence of a specific antidote makes the reversal of the anticoagulant medication less certain. As with other newer anticoagulant drugs, there is little ability to monitor the effectiveness of the antidote . It was unclear if that understanding had been shared widely amongst non-tertiary centres to assist them in managing such patients.
The inquest was told that, at SRFT which is a tertiary centre for neuro surgery/ neurology they have taken steps to set a target for the use of anticoagulant antidote drugs at 90 minutes from presentation. It was unclear if this target was feeding into development of a national protocol. It was unclear how in the absence of national guidance that information was being shared with DGHs which rely on tertiary centres for expertise. At TGH there was no clear target time for the administration of anti-coagulations.
” Open source report
24 Dec 2019 Julie Helen Taylor · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 11 Insufficient availability of acute learning disability beds View source Lack of a vaccination plan for people with Down Syndrome View source Failure to ensure effective psychiatrist and learning disability team communication in medication and care planning View source Incomplete digitisation preventing professionals from accessing each other's notes View source Failure to document decision-making rationales in inpatient notes View source Failure to recognise and put in place reasonable adjustment care plans in acute hospital departments View source Unavailability of appropriately trained wraparound support and care for people with learning disabilities in acute settings View source Failure to recognise chicken pox presentations in junior and dermatology clinicians View source Failure of interagency communication to produce a clear and effective care plan for people with learning disabilities View source Failure to hold formal best interests meetings for key inpatient decisions View source Failure of digital information access between acute and community trusts View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Julie Helen Taylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Julie Helen Taylor, who had Down syndrome and significant learning disabilities, died at Stepping Hill Hospital on 23 September 2018 from pneumonitis following a chicken pox virus infection contracted while awaiting discharge. The concerns included inadequate reasonable-adjustment planning, lack of best-interests meetings and documented decision-making, poor communication between agencies, limited access to suitable learning-disability beds and support, information-sharing difficulties, and delayed recognition of chicken pox.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of acute learning disability beds
Wider context from the report “4. The inquest also heard that a particular challenge existed where a need was identified for an acute learning disability bed. There was a very limited number of such beds available . In Derbyshire at the time of her need the unit had closed to new admissions and therefore any such bed would need to be sourced from outside the country from the limited number of national beds. The limited number of beds meant she may well have been placed many miles from her family and other familiar sights. The fact that one was not available in the county meant that she could not be moved straight away when the need was confirmed at a meeting in August 2018;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Lack of a vaccination plan for people with Down Syndrome
Wider context from the report “7. Julie Taylor was ultimately diagnosed with the chicken pox virus. The delayed diagnosis was due in part to the dermatology registrar not recognising the rash as chicken pox. The inquest heard that the reduction of chicken pox in the general population meant that junior doctors were less likely to recognise the rash and there could be a knock on delay in starting a person on anti-viral medications. This could be detrimental to their health and the eventual outcome as anti-virals were shown to have success in reducing fatalities in adults who contract the virus. There was no vaccination plan in place amongst the population with Down Syndrome although the inquest heard they were more likely statistically to develop it;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure effective psychiatrist and learning disability team communication in medication and care planning
Wider context from the report “5. Prior to her significant deterioration in the community the inquest heard that there was some communication between her community psychiatrist and the learning disability team. There was limited evidence of a joint approach between the psychiatrist and learning disability team where the prescriber in that team changed the medication . Her consultant was not present at the key meetings at the end of July/August and therefore a clear clinical steer from the psychiatrist was not available to the meetings . It was unclear what expectations there should be nationally around attendance and where a key member of the team could not attend how to ensure effective communication of their views before and after meetings ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Incomplete digitisation preventing professionals from accessing each other's notes
Wider context from the report “8. The IT constraints meant that the acute trust could not access the community trusts records. The community trust itself had not fully digitised meaning not all professionals could see each other's notes . The community trust recognised the internal issue and was taking steps to fully roll out an integrated system however communication between trusts digitally was unlikely to improve despite a recognition that it would be beneficial.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to document decision-making rationales in inpatient notes
Wider context from the report “2. No formal best interests meeting(s) was/were held whilst Julie Taylor was an inpatient at the acute hospital. Key decisions were taken regarding what tests to carry out; whether to nurse her and whether to place her on End of Life care without the benefit of a best interests meeting. Decisions were taken with no rationale for them being documented in her notes . The inquest heard that the trust had taken steps to promote the use of best interests meetings/improved documentation in similar cases in the future but that nationally there was a lack of consistency around the use of best interests meetings/documentation of decision making and rationales for those decisions ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and put in place reasonable adjustment care plans in acute hospital departments
Wider context from the report “1. The inquest heard that upon her admission to hospital the Emergency Department, where she spent a prolonged period of time, and Acute Medical Unit (AMU), had not recognised the need for a reasonable adjustment care plan to help them understand her complex needs. One was not put in place until she reached a medical ward . The trust had taken steps to rectify the position and avoid it happening again. The inquest heard that it was unclear if nationally there was a clear understanding in Emergency Departments and AMU's of the need for reasonable care adjustment plans and the impact that lack of provision could have on delivering effective care to those with learning disabilities in an acute setting;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Unavailability of appropriately trained wraparound support and care for people with learning disabilities in acute settings
Wider context from the report “6. In her community care setting Julie Taylor had wraparound care provided by carers who knew her well and were trained to deal with someone with her profound needs. In the acute setting that level of support and care was not available . As a result she became distressed and increasingly less compliant with necessary medical interventions. The inquest heard that the issue of support that can be provided to those with a learning disability in an acute setting is not particular to the trust involved in Julie's death but a national one;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise chicken pox presentations in junior and dermatology clinicians
Wider context from the report “7. Julie Taylor was ultimately diagnosed with the chicken pox virus. The delayed diagnosis was due in part to the dermatology registrar not recognising the rash as chicken pox . The inquest heard that the reduction of chicken pox in the general population meant that junior doctors were less likely to recognise the rash and there could be a knock on delay in starting a person on anti-viral medications. This could be detrimental to their health and the eventual outcome as anti-virals were shown to have success in reducing fatalities in adults who contract the virus. There was no vaccination plan in place amongst the population with Down Syndrome although the inquest heard they were more likely statistically to develop it;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure of interagency communication to produce a clear and effective care plan for people with learning disabilities
Wider context from the report “3. Prior to her admission to the acute hospital there had been on-going discussion about her deteriorating condition and where her care needs could more effectively be met. The inquest heard that both in the community and subsequently in the acute setting there was a need for improved communication between agencies /professionals to ensure a clear, consistent and effective plan was put in to meet the needs of those with a learning disability . In her case it was recognised at the end of July that a learning disability acute bed would be beneficial. Driving that forward was limited by a number of factors including communication between agencies involved ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to hold formal best interests meetings for key inpatient decisions
Wider context from the report “2. No formal best interests meeting(s) was/were held whilst Julie Taylor was an inpatient at the acute hospital. Key decisions were taken regarding what tests to carry out; whether to nurse her and whether to place her on End of Life care without the benefit of a best interests meeting . Decisions were taken with no rationale for them being documented in her notes. The inquest heard that the trust had taken steps to promote the use of best interests meetings/improved documentation in similar cases in the future but that nationally there was a lack of consistency around the use of best interests meetings/documentation of decision making and rationales for those decisions;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure of digital information access between acute and community trusts
Wider context from the report “8. The IT constraints meant that the acute trust could not access the community trusts records . The community trust itself had not fully digitised meaning not all professionals could see each other's notes. The community trust recognised the internal issue and was taking steps to fully roll out an integrated system however communication between trusts digitally was unlikely to improve despite a recognition that it would be beneficial .
” Open source report
16 Dec 2019 Joyce Marchant · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to provide GPs with timely and reliable blood-results and follow-up information View source Shortage of interventional radiologists delaying access to drainage procedures View source Lack of a clear communication strategy and treatment plan between DGHs and tertiary centres View source Delays and impracticability in transferring patients to tertiary centres for drainage procedures 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
Joyce Marchant · 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
Joyce Marchant died at Tameside General Hospital on 1 June 2019 from complications of a liver abscess, including biliary sepsis and multi-organ failure. The report identified concerns about delays in arranging drainage because of limited interventional radiology capacity, delayed communication of abnormal results to her GP through the postal system, and the lack of a clear communication strategy between the district general hospital and tertiary centre.
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 Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to provide GPs with timely and reliable blood-results and follow-up information
Wider context from the report “2. The inquest heard that the Manchester Royal Infirmary use the postal system to provide GPs with information about blood results/follow up information . Faxes are no longer used due to GDPR. The trust propose to move to an email system for notifying GPs recognising that the use of the postal system carries delay and risk of information not reaching the GP(7% was the figure given to the inquest) . Their IT system at this time is not capable of this information transfer and the information was that it would be about another 2-3 years before that was achieved. In the interim they would continue to use the postal system ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Shortage of interventional radiologists delaying access to drainage procedures
Wider context from the report “1. During the course of the Inquest the evidence given was that the delay in offering the drainage procedure was attributable to a shortage of interventional radiologists which meant that the Trust could not accommodate the need for a drainage procedure until 31st May . There was greater availability at tertiary centres but transfers to tertiary centre could take time and not be practicable. The inquest heard that if she had been at the tertiary centre when the abscess was identified she would probably have had the drainage procedure almost straight away;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear communication strategy and treatment plan between DGHs and tertiary centres
Wider context from the report “3. The MRI was the treating centre for Mrs Marchant’s underlying medical problems which led to her deterioration. However there was no evidence of a clear communication strategy or treatment plan involving the DGH and Tertiary Centre . This was attributed in part to the sheer volume of demand on tertiary centres and the extent of support they can provide to DGHs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Delays and impracticability in transferring patients to tertiary centres for drainage procedures
Wider context from the report “1. During the course of the Inquest the evidence given was that the delay in offering the drainage procedure was attributable to a shortage of interventional radiologists which meant that the Trust could not accommodate the need for a drainage procedure until 31st May. There was greater availability at tertiary centres but transfers to tertiary centre could take time and not be practicable . The inquest heard that if she had been at the tertiary centre when the abscess was identified she would probably have had the drainage procedure almost straight away;
” Open source report
13 Dec 2019 Steven Keith Marsland · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Failure to engage families and work with them to support people in the community View source Lack of a clear CMHT policy for effectively engaging families View source Failure to provide regular CMHT contact in the community View source Failure to escalate or discuss very limited post-discharge contact View source Failure to make a follow-up appointment at discharge View source Failure to allocate people moving between borough teams to a community psychiatrist 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
Steven Keith Marsland · 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 Keith Marsland, who had a complex mental health background, was found suspended from a ligature on 10 June 2019; the inquest conclusion was suicide and the medical cause of death was hanging. Concerns included insufficient engagement with his family after discharge, failure to arrange a community psychiatric follow-up appointment, and limited contact with the Community Mental Health Team without escalation or discussion.
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 Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to engage families and work with them to support people in the community
Wider context from the report “1. The inquest heard that his family were very supportive and had attended MDT meetings whilst he was an in-patient. Following his discharge there was no attempt to engage his family and obtain information from them or work with them to support him in the community. There was no clear policy about how a family could be effectively engaged by the CMHT;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear CMHT policy for effectively engaging families
Wider context from the report “1. The inquest heard that his family were very supportive and had attended MDT meetings whilst he was an in-patient. Following his discharge there was no attempt to engage his family and obtain information from them or work with them to support him in the community. There was no clear policy about how a family could be effectively engaged by the CMHT ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to provide regular CMHT contact in the community
Wider context from the report “3. The inquest heard that it was recognised as part of his discharge planning that there should be regular contact in the community with the CMHT. That did not happen and there was no escalation or discussion about the picture of very limited contact as it evolved post discharge.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate or discuss very limited post-discharge contact
Wider context from the report “3. The inquest heard that it was recognised as part of his discharge planning that there should be regular contact in the community with the CMHT. That did not happen and there was no escalation or discussion about the picture of very limited contact as it evolved post discharge .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to make a follow-up appointment at discharge
Wider context from the report “2. The inquest heard that he was treated as an in-patient by the Pennine Care team within Stockport MBC. His consultant whilst he was an in-patient was part of the Stockport Team. If he had been a Stockport Resident he would have been discharged under the care of that consultant in the community and had a follow up appointment booked with that Doctor at discharge. However because he was a Tameside Resident at discharge his care moved to the Tameside Borough Pennine Care Team. That meant he had to be allocated to a community psychiatrist based there. That did not happen and no follow up appointment was made ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate people moving between borough teams to a community psychiatrist
Wider context from the report “2. The inquest heard that he was treated as an in-patient by the Pennine Care team within Stockport MBC. His consultant whilst he was an in-patient was part of the Stockport Team. If he had been a Stockport Resident he would have been discharged under the care of that consultant in the community and had a follow up appointment booked with that Doctor at discharge. However because he was a Tameside Resident at discharge his care moved to the Tameside Borough Pennine Care Team. That meant he had to be allocated to a community psychiatrist based there. That did not happen and no follow up appointment was made;
” Open source report
1 Oct 2019 Oliver Sharp · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure of schools to recognise risks and early signs associated with acceleration ahead of chronological school age View source Additional challenge associated with disability labelling for ageing children with autism View source Long waiting lists for autism assessments View source Variation and limited transition provision in post-16 mental health services View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Oliver Sharp · 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 Sharp died after taking a fatal dose of heroin; his death was confirmed at Wythenshawe Hospital on 18 October 2018. The inquest identified concerns about failures by mental health services to recognise and respond to his increasing level of risk during his transition from child and adolescent mental health services to reduced post-16 provision, as well as concerns about delays in autism assessment and variation in post-16 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 Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure of schools to recognise risks and early signs associated with acceleration ahead of chronological school age
Wider context from the report “During the inquest evidence was heard that acceleration ahead of a chronological school age might cause relatively few difficulties in peer relationships up to about year 9 but post that as children entered adolescence it could become a significant issue impacting a child’s mental health and ability to cope . Where it did happen, there needed to be an understanding by schools of the risks and early signs indicating a need for additional support to try to reduce the likelihood of self-harming behaviours and the potential need for additional support.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Additional challenge associated with disability labelling for ageing children with autism
Wider context from the report “The inquest heard that Oliver had found the autism label and the label of disability that was attached to it very difficult to accept as time went on . There was evidence that particularly with ageing children with autism the idea that they had a disability created additional challenge .
The language that it would have been more helpful to use widely would have been difference rather than disability.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Long waiting lists for autism assessments
Wider context from the report “The inquest was told that it is important for autism to be diagnosed as early as possible so that appropriate support can be put in place. Early diagnosis was impacted by a national picture of long waiting lists for ADOS assessments . In Stockport there was approximately a 6 month waiting list for assessment . This was against a national picture of 12-24 month waits in some areas .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Variation and limited transition provision in post-16 mental health services
Wider context from the report “The inquest was told that the provision of mental health services post 16 varies widely across the country . In some areas there is a CAMHS 16-25 mental health service provision similar to the national 16 and under service whereas in other areas there a limited transition service or move back to primary care for re-referral to adult services . The inquest was told that this creates a cliff edge high risk situation for adolescents . The reason for the difference was resources and decisions taken by CCGs.
” Open source report
30 Sep 2019 Charles Williamson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Insufficient availability of appropriate neuro-rehabilitation beds in Greater Manchester View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Charles Williamson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Charles Williamson sustained a traumatic brain injury after falling in Portugal and underwent treatment and rehabilitation in several hospitals. He later developed infections and deteriorated; the report raised concern that a shortage of appropriate neuro-rehabilitation beds in Greater Manchester could delay effective rehabilitation and increase the risk of complications leading to death.
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 Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of appropriate neuro-rehabilitation beds in Greater Manchester
Wider context from the report “The inquest heard that following neurological incidents such as those sustained by Mr Williamson it will often be the case that a key to returning to baseline or closer to baseline is effective and early neuro-rehabilitation. The inquest was told that a shortage of appropriate neuro-rehabilitation beds in Greater Manchester was in some cases preventing early effective neuro-rehabilitation and increasing the risk of complications which could lead to death.
” Open source report
30 Sep 2019 Graham Earl · Prevention of Future Deaths report Manchester South
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Concerns raised 5 Failure of GPs to recognise the link between the therapy and Pulmonary Fibrosis View source Failure to seek early guidance from the prescribing secondary care physician View source Failure to refer prescription amendments to the secondary care doctor for medication not started in primary care View source CCG classification of the drug as green despite known side effects View source Lack of GP awareness of escalation procedures for medication side effects View source See 2 more concerns
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Graham Earl · 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
Graham Earl had pulmonary fibrosis diagnosed while receiving Amiodarone therapy and was not referred back to the cardiologist. He later developed influenza, deteriorated, and died at Stepping Hill Hospital on 16 February 2019. The principal concerns were that the link between Amiodarone and pulmonary fibrosis was not recognised promptly, the medication was amended without reference to secondary care, and there was insufficient awareness of escalation procedures for side effects.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure of GPs to recognise the link between the therapy and Pulmonary Fibrosis
Wider context from the report “1. The GPs involved did not understand or recognise the known link between the therapy and Pulmonary Fibrosis and did not seek guidance from the prescribing secondary care physician at an early stage. The evidence was that the advice would have been to stop prescribing immediately;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to seek early guidance from the prescribing secondary care physician
Wider context from the report “1. The GPs involved did not understand or recognise the known link between the therapy and Pulmonary Fibrosis and did not seek guidance from the prescribing secondary care physician at an early stage . The evidence was that the advice would have been to stop prescribing immediately;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to refer prescription amendments to the secondary care doctor for medication not started in primary care
Wider context from the report “2. A GP amended the prescription subsequently without reference to the secondary care doctor despite the fact that this is not a medication started in primary care ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation CCG classification of the drug as green despite known side effects
Wider context from the report “4. The drug is currently green on the CCG classification . In other CCG areas it is amber given the known side effects .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Health and Social Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Lack of GP awareness of escalation procedures for medication side effects
Wider context from the report “3. The indication was that GPs involved were not aware of what they should do if there were side effects from the medication in terms of escalation ;
” 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