17 Oct 2024 Leslie Andrew Swindells · Prevention of Future Deaths report Manchester South
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Concerns raised 9 Unclear operation of supervision for mental health assistant practitioners View source Greater difficulty assessing mental health by telephone than face to face View source Failure to identify the practitioner’s role and qualifications during mental health assessments View source Lack of professional or supervisory body membership for mental health assistant practitioners View source Poor documentation of mental health assessment content View source Insufficient mental health training for practitioners conducting mental health reviews View source Failure to restrict mental health reviews to practitioners with adequate mental health understanding View source Failure to provide competent triage and allocation of mental health appointments View source Lack of clarity among GPs about the scope of routine mental health practitioner roles View source See 6 more concerns
Responses linked to these concerns
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AI-generated summary
Leslie Andrew Swindells · 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
Leslie Andrew Swindells had a complex mental health background and, after his mental health deteriorated, was found unresponsive at home with self-inflicted puncture wounds to the neck. The concerns included assessment by a practitioner with limited mental-health training, lack of appropriate triage and escalation, failure to recognise and mitigate risk, telephone-based assessment, inadequate documentation, and unclear supervision arrangements.
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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 gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Unclear operation of supervision for mental health assistant practitioners
Wider context from the report “4. The evidence was that where GP practices chose to deploy staff with such limited qualifications to see those who needed treatment for their mental health it was essential that all those in the practice understood the limitations of the role and that there was close supervision of the practitioner .
5. The inquest heard that it was envisaged by the practice that the GP on duty would have a supervisory role. However it was unclear how this operated other than by the mental health assistant escalating a concern to the duty GP .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Greater difficulty assessing mental health by telephone than face to face
Wider context from the report “6. The assessment was carried out by telephone. The inquest was told that approximately 80% of the practitioner’s mental health reviews took place in this way although it was accepted in evidence that it was far more challenging to assess an individual’s mental health via telephone than face to face . During the conversation the practitioner did not identify their role or their qualifications to Mr Swindells.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to identify the practitioner’s role and qualifications during mental health assessments
Wider context from the report “6. The assessment was carried out by telephone. The inquest was told that approximately 80% of the practitioner’s mental health reviews took place in this way although it was accepted in evidence that it was far more challenging to assess an individual’s mental health via telephone than face to face. During the conversation the practitioner did not identify their role or their qualifications to Mr Swindells .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Lack of professional or supervisory body membership for mental health assistant practitioners
Wider context from the report “8. Practitioners such as the one who saw Mr Swindells are not part of a professional /supervisory body .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Poor documentation of mental health assessment content
Wider context from the report “7. The documentation of the practitioner was poor and did not reflect the content of the conversation which had been recorded and was available to the inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health training for practitioners conducting mental health reviews
Wider context from the report “1. The inquest heard evidence that the practitioner who saw Mr Swindells had very limited training in mental health and was employed in a role described as a mental health assistant practitioner. The evidence was that there was limited understanding of the scope of their role by GPs and what was covered by the term routine mental health 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 gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict mental health reviews to practitioners with adequate mental health understanding
Wider context from the report “2. In Mr Swindells case the evidence was that he should never have had a review undertaken by someone with such a limited an understanding of mental health and that lack of understanding of mental health meant that the practitioner did not recognise the level of risk Mr Swindells posed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to provide competent triage and allocation of mental health appointments
Wider context from the report “3. The appointment had been booked via the reception team with no triage by a doctor following a telephone call to the practice. The evidence was that a shortage of trained reception/admin staff meant that an agency worker was screening calls that day and had a limited understanding of how patients needed to be allocated .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity among GPs about the scope of routine mental health practitioner roles
Wider context from the report “1. The inquest heard evidence that the practitioner who saw Mr Swindells had very limited training in mental health and was employed in a role described as a mental health assistant practitioner. The evidence was that there was limited understanding of the scope of their role by GPs and what was covered by the term routine mental health appointments .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Emphasise face-to-face assessment opportunities for new mental health presentations in shared case learning.
Verbatim wording from the response “As part of the learning to be shared following this case, we will emphasise the need for clinical staff to ensure they have explored all opportunities to see new presentations of mental health conditions as a face-to-face consultation rather than via telephone.” Source location Response from GTD Healthcare
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide paper copies of clinical templates for use when electronic templates are inaccessible.
Verbatim wording from the response “We recognise the concerns that you have raised into the documentation concerning Mr Swindells' appointment with the Assistant Practitioner. We have outlined at Section Two above the changes which were introduced to the standard templates utilised by Assistant Practitioners in their mental health and depression reviews. In addition to this, to ensure that accurate contemporaneous records are kept of all appointments with patients, clinicians have also been provided with hard copies of the templates to be used if they are unable to access the clinical system templates due to IT issues.” Source location Response from GTD Healthcare
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Cease employing Assistant Practitioners in Mental Health.
Verbatim wording from the response “• Following consultation, on 6th November 2024 the Director of Nursing and Allied Health Professionals made the decision that going forward, Assistant Practitioners in Mental Health would not be employed within gtd. At present, there are no Assistant Practitioners in Mental Health employed by gtd.” Source location Response from GTD Healthcare
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce an interim reception triage template guiding symptom questions, appointment allocation and escalation to the on-call GP.
Verbatim wording from the response “• We introduced an interim reception triage template to assist reception staff with their initial data gathering and to ensure that the right type of appointment was booked with an appropriate clinician. This template prompts the receptionist to ask key questions and then guides them to an appropriate outcome, for example, urgent same-day appointments with a registered clinician are recommended in cases where the patient is demonstrating severe mental health problems (including suicidal ideation, new hallucinations, delusions or paranoia). In any cases where they are uncertain about the appropriate outcome or concerned about the patient's symptoms, receptionists are required to discuss the patient with the on-call GP.” Source location Response from GTD Healthcare
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review non-registered practitioner roles, remits, responsibilities, competencies and management systems for safe practice.
Verbatim wording from the response “• As gtd has other Assistant Practitioner roles, we commissioned a review of all non-registered practitioner roles, including their remit and responsibilities, to ensure that all roles have the required competency and management systems in place for safe practice. This review was completed on the 27 November 2024. The policy and subsequent recommendations will be ratified at the Clinical Quality Improvement Group scheduled for 8th January 2025. The outcome and recommendations from the review will be launched on the week commencing the 12th January 2025.” Source location Response from GTD Healthcare
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a digital front door requiring clinician review of online or staff-completed triage requests before appointment allocation.
Verbatim wording from the response “• We introduced a 'digital front door' at Hattersley Group Practice on the 18th November 2024. This online tool, which has already been successfully launched in other gtd practices, requires the patient or a family member to complete an online triage form. This is then reviewed by a doctor or an advanced clinical practitioner to determine the appropriate pathway for the patient to manage their request. Where a patient is unable to access the online forms, they can contact the practice directly and the staff will go through the questions and complete the form on their behalf so that the form can then be processed in the same way as had the patient completed it themselves. Forms are reviewed daily and the system is integrated with the Electronic Patient Record, EMIS, so that requests are saved directly to the patient's record with one click.” Source location Response from GTD Healthcare
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Restrict Assistant Practitioner appointment-book access to patients triaged by a registered clinician.
Verbatim wording from the response “• To further ensure that all patients were seen by an appropriate clinician, access was restricted to Assistant Practitioners' appointment books, so that only patients who have been triaged by a registered clinician could be added. As the Assistant Practitioner in Mental Health Role has been dissolved, this action is no longer required.” Source location Response from GTD Healthcare
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce staff guidance and patient-facing posters and web materials explaining clinicians’ roles and qualifications.
Verbatim wording from the response “During the appointment, the Assistant Practitioner introduced himself by name, however it is accepted that he did not identify his specific role, qualifications or clarify that he was not a GP. Following this incident, we have produced guidance for staff on gtd's expectations of how they introduce themselves to patients to ensure that patients understand who is providing their care. We have also developed posters to put up in our practices that will also be available on the practices' web pages to ensure that patients are able to recognise the different clinicians involved in their care.” Source location Response from GTD Healthcare
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch the role-review outcomes and recommendations and share role scopes and responsibilities with relevant staff.
Verbatim wording from the response “• As gtd has other Assistant Practitioner roles, we commissioned a review of all non-registered practitioner roles, including their remit and responsibilities, to ensure that all roles have the required competency and management systems in place for safe practice. This review was completed on the 27 November 2024. The policy and subsequent recommendations will be ratified at the Clinical Quality Improvement Group scheduled for 8th January 2025. The outcome and recommendations from the review will be launched on the week commencing the 12th January 2025.” Source location Response from GTD Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the induction process for agency staff to cover key patient-direction and clinician-allocation processes.
Verbatim wording from the response “• We have reviewed the induction process for agency staff to ensure that they are aware of all key processes within the practice for directing patients to the appropriate clinicians.” Source location Response from GTD Healthcare
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing access to a GP or Advanced Clinical Practitioner provides supervision and escalation support for Assistant Practitioners in each practice.
Verbatim wording from the response “These Assistant Practitioners were able to work independently of direct supervision for routine mental health reviews, however they were unable to see any new presentations or make any clinical decisions or plans without the agreement of a senior clinician. Therefore, a supervisor had to be readily available and within close proximity to the Assistant Practitioner to provide support. In each practice, gtd ensures that there is always access to a GP or Advanced Clinical Practitioner, should an Assistant Practitioner need to escalate any concerns about a patient.” Source location Response from GTD Healthcare
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assistant Practitioners are limited to routine, low-level mental health reviews and cannot assess new or deteriorating presentations without senior clinician involvement.
Verbatim wording from the response “In accordance with their job description, the roles and responsibilities of Assistant Practitioners in Mental Health include: completion of annual severe mental illness ("SMI") physical health checks, the regular depression reviews arranged following an initial mental health consultation with a registered practitioner and also providing support for completion of ADHD and Autism assessments. When conducting the SMI health checks and depression reviews, Assistant Practitioners are required to complete a gtd template, and escalate any patients who are identified as vulnerable and at high-risk of self-harm or harm to others, to a registered practitioner for further assessment. The scope of the Assistant Practitioner in Mental Health role is limited to non-urgent, low-level mental health reviews.” Source location Response from GTD Healthcare
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Routine two-week mental health reviews may be conducted by telephone because face-to-face consultation is not considered necessary for that limited purpose.
Verbatim wording from the response “Telephone reviews are an accepted practice for routine two-week mental health reviews as the purpose is to ensure that the patient has collected, is compliant with taking their medication, and that there are no side effects. A face-to-face consultation is not deemed necessary for this type of review, but a referral to GP/ACP would be initiated if any concerns were identified and face to face appointment booked in.” Source location Response from GTD Healthcare
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20 Aug 2015 Elsie Clarke · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 12 Failure of Out of Hours doctors to keep proper timed attendance records View source Failure to provide appropriate advice on calling the Coroner or police View source Failure to maintain food and hydration records View source Failure to arrange GP attendance for residents not fully registered with a local GP View source Lack of understanding of prompt Care Quality Commission reporting requirements View source Gap in Out of Hours doctors’ training on reporting deaths to the Coroner View source Failure to seek assessment from an available visiting GP View source Lack of staff training in appropriate use of 999 or 111 View source Failure to keep proper and sufficient resident care notes View source Failure to provide full and effective shift handover View source Failure of Out of Hours doctors to carry or wear a watch for vital-sign assessment View source Poor observation of residents’ basic needs 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.
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AI-generated summary
Elsie Clarke · 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
Elsie Clarke was a resident at Hurst Hall care centre and developed significant pneumonia on 10 February 2015, dying later that day. The report identified concerns about missed opportunities to summon medical help, inadequate staff training and observations, failures in record-keeping and handover, and deficiencies in out-of-hours medical processes and death reporting.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure of Out of Hours doctors to keep proper timed attendance records
Wider context from the report “(9) There was an obvious gap in the training of Out of Hours doctors in a number of aspects including (a) Keeping proper timed records of each attendance on a patient (b) Wearing or carrying a watch so as to be able to assess pulse rates, respiration rates etc. (c) Process for reporting deaths as necessary to the Coroner
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate advice on calling the Coroner or police
Wider context from the report “(10) The doctor advised the Home that in the present case there was no need to call the Coroner/police
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain food and hydration records
Wider context from the report “(6) There was a complete failure to maintain food and hydration records .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange GP attendance for residents not fully registered with a local GP
Wider context from the report “(2) The staff did not know how to arrange for the attendance of a GP for a resident who was not yet fully registered with a local GP . In particular they appeared completely ignorant of the existence of a “Temporary GP Registration form” .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of prompt Care Quality Commission reporting requirements
Wider context from the report “(4) There seemed to be a complete lack of understanding about the legal requirement for prompt reporting of such matters as occurred in this case to the Care Quality Commission .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Gap in Out of Hours doctors’ training on reporting deaths to the Coroner
Wider context from the report “(9) There was an obvious gap in the training of Out of Hours doctors in a number of aspects including (a) Keeping proper timed records of each attendance on a patient (b) Wearing or carrying a watch so as to be able to assess pulse rates, respiration rates etc. (c) Process for reporting deaths as necessary to the Coroner
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to seek assessment from an available visiting GP
Wider context from the report “(5) When a local GP was visiting another patient at the Home, the staff seemed unaware that they could and should have asked that doctor to look at this patient/resident .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training in appropriate use of 999 or 111
Wider context from the report “(1) There was an apparent lack of training for the staff at Hurst Hall in the appropriate use of calling either 999 or 111 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to keep proper and sufficient resident care notes
Wider context from the report “(7) There was a failure to keep proper and sufficient notes of the care afforded to each resident .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to provide full and effective shift handover
Wider context from the report “(8) There was a failure to give full and effective “hand-over” at each shift change .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure of Out of Hours doctors to carry or wear a watch for vital-sign assessment
Wider context from the report “(9) There was an obvious gap in the training of Out of Hours doctors in a number of aspects including (a) Keeping proper timed records of each attendance on a patient (b) Wearing or carrying a watch so as to be able to assess pulse rates, respiration rates etc. (c) Process for reporting deaths as necessary to the Coroner
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Poor observation of residents’ basic needs
Wider context from the report “(3) The level and quality of observation of the residents were very poor and did not include even some of the most basic issues such as whether the patient was warm, thirsty etc.
” Open source report
8 Jul 2015 Amanda Jane Ellams · Prevention of Future Deaths report Manchester South
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Concerns raised 5 Failure to maintain complete and accessible medical and nursing records View source Failure of the out-of-hours District Nursing telephone system to answer calls View source Failure to ensure safe oxygen saturation levels before discharge View source Failure to adequately record and monitor blood oxygen levels View source Failure to prevent unsafe disconnection of oxygen supply and departure from the ward 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.
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AI-generated summary
Amanda Jane Ellams · 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
Amanda Jane Ellams died approximately four days after surgery to repair an incisional hernia in February 2015. The concerns included inadequate medical and nursing record-keeping, incomplete pre-operative medical information, discharge despite low oxygen saturations and inadequate oxygen monitoring, and three unanswered calls to the out-of-hours District Nursing telephone service during the night of her 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 gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain complete and accessible medical and nursing records
Wider context from the report “1. During the course of the inquest it was apparent that the standard of note keeping at the Alexandra Hospital (both medical and nursing) was well below that which would be generally regarded as satisfactory . There was even one attendance on the patient by the consultant surgeon in February (according to the surgeon’s evidence to me) for which there was no written record whatsoever . The surgeon conceded that he did not have a full medical history available to him pre-operatively and he was not aware of all the prescribed drugs which she was taking . (BMI Healthcare)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure of the out-of-hours District Nursing telephone system to answer calls
Wider context from the report “3. The out-of-hours telephone system for the District Nursing team in Tameside area was operated by Good HealthCare (which also provides the out-of-hours GP service in that area). It was apparent that during the night of her death, Mrs Ellams had made three separate calls to the telephone number she had been given to contact the District Nurses and none of those calls was answered . The duration of the unanswered calls was 2 minutes, 1 minute 50 seconds and 1 minute 14 seconds respectively. In giving his evidence, the Chief Executive of GTD conceded that “it is a flawed system” . (GTD Healthcare)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure safe oxygen saturation levels before discharge
Wider context from the report “2. The Alexandra Hospital Staff Nurse conceded that Mrs Ellams was discharged from hospital even though it is now clear that her oxygen saturations were still too low for such discharge to take place . There was what appeared to be a very lax attitude to recording and monitoring the Blood/Oxygen levels and the patient was allowed to disconnect her oxygen supply and walk out of the ward to go for a cigarette. (BMI Healthcare)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately record and monitor blood oxygen levels
Wider context from the report “2. The Alexandra Hospital Staff Nurse conceded that Mrs Ellams was discharged from hospital even though it is now clear that her oxygen saturations were still too low for such discharge to take place. There was what appeared to be a very lax attitude to recording and monitoring the Blood/Oxygen levels and the patient was allowed to disconnect her oxygen supply and walk out of the ward to go for a cigarette. (BMI Healthcare)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to gtd healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent unsafe disconnection of oxygen supply and departure from the ward
Wider context from the report “2. The Alexandra Hospital Staff Nurse conceded that Mrs Ellams was discharged from hospital even though it is now clear that her oxygen saturations were still too low for such discharge to take place. There was what appeared to be a very lax attitude to recording and monitoring the Blood/Oxygen levels and the patient was allowed to disconnect her oxygen supply and walk out of the ward to go for a cigarette . (BMI Healthcare)
” 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