19 Jan 2018 William Myers · Prevention of Future Deaths report Manchester West
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Concerns raised 8 Failure to circulate important clinical risk information to treating clinicians View source Failure to undertake multidisciplinary case conference reassessment by a forensic psychiatrist View source Inconsistent continuity of psychiatric care across teams and wards View source Failure to act on recommendations to consider Mental Health Act assessment View source Gaps in clinical record keeping hindering treatment coordination and discharge accountability View source Failure to identify complex cases early and assign them to an appropriately qualified psychiatrist View source Failure of psychiatric consultants to confer sufficiently on a clear management plan View source Insufficient availability of inpatient psychiatric beds for complex individuals View source See 5 more concerns
Responses linked to these concerns
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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
William Myers · 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
William Myers, aged 79, was unlawfully killed; the medical cause of death was multiple stab wounds. The principal concerns related to inconsistent and inappropriate community care of his attacker, including failures to coordinate treatment, recognise warning signs, share relevant information, act on recommendations for Mental Health Act assessment, and maintain adequate records.
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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; that does not assign responsibility.
PFD Monitor interpretation Failure to circulate important clinical risk information to treating clinicians
Wider context from the report “(3) Valuable background information was not circulated to those involved in his treatment with the result that they were deprived of the crucially important medical history of the potential risks (particularly the attacker was no longer taking the medication which controlled his behaviour and was once again resorted to using illicit drugs). An example of this concerns a 20 page discharge report prepared by a Consultant Forensic Psychiatrist at the time the attacker was being prepared to leave Ashworth High Security Hospital. This report not seem to have been material to the Care Coordinator, the GP nor the Consultant Psychiatrist who undertook treatment on two different psychiatric wards and in the community.
” Open source report × Source evidence
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; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake multidisciplinary case conference reassessment by a forensic psychiatrist
Wider context from the report “(2) A variety of incidents should have alerted the clinicians and others involved in his management to the need for a multi-disciplinary case conference reassessment by the Forensic Psychiatrist . Neither of these took place and in consequence warning signs of impending or actual violence were not recognised . Examples include being found by the Police in a public place in possession of a bladed article when under the influence of some illicit substance and admitting he was hearing voices commanding him to kill people.
” Open source report × Source evidence
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; that does not assign responsibility.
PFD Monitor interpretation Inconsistent continuity of psychiatric care across teams and wards
Wider context from the report “(1) The care and treatment provided to Mr Lound's attacker ('the attacker') in 2015/16 whilst in the community was inconsistent and/or inappropriate management strategy . Instead of being treated by the same team of psychiatric clinicians, he was admitted to four different psychiatric wards during 2015 . The consultants involved in his treatment did not confer sufficiently to produce a clear management plan.
” Open source report × Source evidence
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; that does not assign responsibility.
PFD Monitor interpretation Failure to act on recommendations to consider Mental Health Act assessment
Wider context from the report “(4) On three occasions during 2015 other clinicians who encountered the attacker recommended that a Mental Health Act assessment be considered with a view to him being detained . These recommendations were not acted upon . Judgements made by Consultant psychiatrists were not acted upon, preferably by a second opinion in the least, but preferably by a Forensic Psychiatrist, as this has been verified by the benefit of hindsight, the attacker's propensity to violent conduct may well have been triggers by a Mental Health Act assessment.
” Open source report × Source evidence
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; that does not assign responsibility.
PFD Monitor interpretation Gaps in clinical record keeping hindering treatment coordination and discharge accountability
Wider context from the report “(5) Gaps in record keeping hindered the coordination of treatment . Examples included a void in the medical notes to explain why the number of letters had been transferred from one psychiatric ward to another (with a different consultant and clinical team), a discharge in his absence (taking place in October 2015) without any record of the assessment having been produced by the same team as to how the risk followed up and why he was to be benefited, nor an explanation as to who had authorised the discharge and the discharge 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; that does not assign responsibility.
PFD Monitor interpretation Failure to identify complex cases early and assign them to an appropriately qualified psychiatrist
Wider context from the report “Overall, the lingering concern is complex such as this are not identified early enough and managed by an identified and appropriately qualified psychiatrist . There should be a clear delineation of all the clinicians and agencies involved, by way of periodic case conferences with reasons and decisions made being recorded and circulated. The scarcity of inpatient psychiatric beds fuels the concern that complex individuals are being treated in the community rather than controlling the risks they present by having them remain in hospital until such crimes as their condition has been shown to have stabilised.
” Open source report × Source evidence
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; that does not assign responsibility.
PFD Monitor interpretation Failure of psychiatric consultants to confer sufficiently on a clear management plan
Wider context from the report “(1) The care and treatment provided to Mr Lound's attacker ('the attacker') in 2015/16 whilst in the community was inconsistent and/or inappropriate management strategy. Instead of being treated by the same team of psychiatric clinicians, he was admitted to four different psychiatric wards during 2015. The consultants involved in his treatment did not confer sufficiently to produce a clear management plan .
” Open source report × Source evidence
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; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of inpatient psychiatric beds for complex individuals
Wider context from the report “Overall, the lingering concern is complex such as this are not identified early enough and managed by an identified and appropriately qualified psychiatrist. There should be a clear delineation of all the clinicians and agencies involved, by way of periodic case conferences with reasons and decisions made being recorded and circulated. The scarcity of inpatient psychiatric beds fuels the concern that complex individuals are being treated in the community rather than controlling the risks they present by having them remain in hospital until such crimes as their condition has been shown to have stabilised.
” Open source report
19 Apr 2017 Elaine Talbot · Prevention of Future Deaths report Manchester North
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Concerns raised 1 Lack of urgent direct access to CT scanning for primary care clinicians 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
Elaine Talbot · 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
Elaine Talbot had experienced headaches, nausea and vomiting for approximately three weeks before being taken to hospital on 31 August 2016, where she was diagnosed with migraine and discharged without a CT scan. She returned extremely unwell on 7 September 2016; a CT scan identified a large brain mass, and she died at Fairfield General Hospital the same day following a cardiac arrest. The principal concern was the lack of urgent direct access to CT scanning for primary-care clinicians, which could potentially affect outcomes for others.
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; that does not assign responsibility.
PFD Monitor interpretation Lack of urgent direct access to CT scanning for primary care clinicians
Wider context from the report “1. During the course of the evidence heard at inquest, the deceased's GP explained that he had no ability to make a direct urgent referral for urgent CT scanning – unlike other GPs in neighbouring towns. He considered that such accessibility would be beneficial. Whilst it is unlikely that earlier scanning in Mrs Talbot's case would have materially altered the very sad outcome, I am concerned that the lack of urgent direct access to CT scanning by clinicians working in primary care may potentially have a bearing upon the outcome for others in terms of prevention of future deaths.
This appears to be a commissioning issue and that is why I am directing this PFD form to you. I further, your letter of the 7th April 2017 did not address the issue sufficiently.
” Open source report
Concerns raised 2 Lack of recording of reasons, requests or decisions to stop prescribing a drug in clinical records View source Lack of standard directions for managing requests to restart a discontinued medication 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
Fred Whittaker · 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
Fred Whittaker, who had schizophrenia and was known to abuse drugs and alcohol, attended hospital with chest pains and drowsiness after taking codeine, alcohol and methadone, but self-discharged and went home. He was found dead in his flat the following morning; the inquest concluded that he died from developing bronchopneumonia and combined codeine, methadone and alcohol toxicity. A principal concern was that Clonazepam was restarted in error after his psychiatrist had requested that it be stopped, reflecting inadequate recording and procedures for discontinued prescriptions.
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; that does not assign responsibility.
PFD Monitor interpretation Lack of recording of reasons, requests or decisions to stop prescribing a drug in clinical records
Wider context from the report “An important issue in the Inquest was the continued prescription of Clonazepam by the Heaton Moor Medical Centre despite the written request on 17th August 2015, from Mr Whittaker’s treating psychiatrist, ████████ that this medication be stopped.
The evidence given to me by ████████ a partner at the Heaton Moor Medical Centre, suggests that although the prescription was stopped it was started again in error.
████████ advised that,
a) On receipt of ████████ request the drug was moved from the Repeat Prescription list to the Past Prescription list, without any reference in the records of the reason as to why the Clonazepam was being stopped.
b) On or about the 19th August 2015 the pharmacy which administered Mr Whittaker’s medication requested a repeat prescription.
c) It was likely that upon receiving that request Clonazepam was simply moved back on to the repeat prescription by one of the doctors at the Practice on being advised by an administrator of the Pharmacy’s request.
This is clearly an unacceptable error.
I accept that, on this occasion, this error played no part in Mr Whittaker’s demise but it is not difficult to imagine a completely different set of circumstances where such an error would give rise to a risk of death.
████████ evidence was that there were no standard directions as to how to manage this as a situation and that other practices may adopt the same simple policy of transferring the drug from one list to another.
1. That Heaton Moor Medical Centre does not have a mechanism whereby the reasons or requests or decisions that a patient is no longer to be prescribed a particular drug are recorded in the clinical records.
2. That this poor practice may not be limited to Heaton Moor Medical Centre and is replicated in many GP practices in the Northwest and indeed, nationally.
” Open source report × Source evidence
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; that does not assign responsibility.
PFD Monitor interpretation Lack of standard directions for managing requests to restart a discontinued medication
Wider context from the report “An important issue in the Inquest was the continued prescription of Clonazepam by the Heaton Moor Medical Centre despite the written request on 17th August 2015, from Mr Whittaker’s treating psychiatrist, ████████ that this medication be stopped.
The evidence given to me by ████████ a partner at the Heaton Moor Medical Centre, suggests that although the prescription was stopped it was started again in error.
████████ advised that,
a) On receipt of ████████ request the drug was moved from the Repeat Prescription list to the Past Prescription list, without any reference in the records of the reason as to why the Clonazepam was being stopped.
b) On or about the 19th August 2015 the pharmacy which administered Mr Whittaker’s medication requested a repeat prescription.
c) It was likely that upon receiving that request Clonazepam was simply moved back on to the repeat prescription by one of the doctors at the Practice on being advised by an administrator of the Pharmacy’s request.
This is clearly an unacceptable error.
I accept that, on this occasion, this error played no part in Mr Whittaker’s demise but it is not difficult to imagine a completely different set of circumstances where such an error would give rise to a risk of death.
████████ evidence was that there were no standard directions as to how to manage this as a situation and that other practices may adopt the same simple policy of transferring the drug from one list to another.
1. That Heaton Moor Medical Centre does not have a mechanism whereby the reasons or requests or decisions that a patient is no longer to be prescribed a particular drug are recorded in the clinical records.
2. That this poor practice may not be limited to Heaton Moor Medical Centre and is replicated in many GP practices in the Northwest and indeed, nationally.
” 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