21 Oct 2025 Amber Grace Walker · Prevention of Future Deaths report Dorset
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Concerns raised 2 Failure to consistently discuss SUDEP with patients with epilepsy View source Lack of SUDEP training for doctors View source
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AI-generated summary
Amber Grace Walker · 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
Amber Grace Walker, who had epilepsy and uncontrolled nocturnal tonic-clonic seizures, was found deceased at home on 19 April 2023. A post-mortem examination identified Sudden Unexpected Death in Epilepsy (SUDEP) as the medical cause of death. The concerns were that SUDEP and Amber’s individual risk, including the implications of declining increased medication, were not discussed with her, and that SUDEP discussions and related training for doctors were not consistent or universal.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Guy'S and St Thomas' NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consistently discuss SUDEP with patients with epilepsy
Wider context from the report “i. Doctors can be reluctant to discuss SUDEP with patients and/or presume it is a discussion that has been had at previous appointments(s) with colleagues that does not need repeating. There are tools, such as the SUDEP Action-produced “SUDEP Checklist”, that can facilitate such a discussion, but they are not used universally. The SUDEP Checklist can be used by any medical practitioner who may come into contact with a patient with epilepsy. Discussions about SUDEP ensure that patients are aware of the general risks of SUDEP, the risks that are specific to the patient and the measures that can be taken to mitigate the risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Guy'S and St Thomas' NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of SUDEP training for doctors
Wider context from the report “ii. SUDEP is not covered in the medical training of doctors , despite is being the leading cause of death in patients with a diagnosis of epilepsy. It is not only neurologists that will encounter patients with epilepsy where a discussion regarding SUDEP may be required , as demonstrated by Amber’s experience.
” Open source report
15 Oct 2019 Mr Derek Weaver · Prevention of Future Deaths report Inner South London
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Concerns raised 1 Lack of capacity for regional referrals during surges View source
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Mr Derek Weaver · Prevention of Future Deaths report
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Report summary
Mr Derek Weaver was admitted to hospital with community-acquired pneumonia and an empyema, which required surgery. He died on 31 May 2018 after becoming septic and developing a systemic inflammatory response following delayed transfer for surgery. The principal concern was that the 14-day transfer delay, related to exceptional pressure on bed capacity, contributed to his death and that similar risks could recur during referral surges without additional capacity.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Guy'S and St Thomas' NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of capacity for regional referrals during surges
Wider context from the report “A consultant thoracic surgeon who was involved in his care after transfer said that had a higher chance of death because surgery was at a time of SIRS. If he had been transferred earlier he would have had surgery when he was not septic. It would have been two stages, the first being key hole surgery, with mortality of only 1 in 100. That may have obviated the necessity of second stage decortication surgery, with mortality of 5%, but it was probably needed anyway. The delay in transfer related to a surge in referrals, limiting capacity. Most regional referrals of this sort needed to be treated at weekends to maintain treatment of cancer cases in the week. There had been pressure to secure greater resources. The risk of potentially preventable deaths will recur whenever there is such a surge in referrals and be mitigated by provision of more beds.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a consultant-of-the-week system to triage and manage all thoracic surgery referrals.
Verbatim wording from the response “In April 2019, to improve the Thoracic Surgery Service, the referrals system was changed to a “consultant of the week” system. A single consultant and their team take responsibility for the triage and management of all referrals for the week, with the aim of improving the prioritisation of patients for transfer in to the Thoracic Surgery Service. The “consultant of the week” system will be audited to ascertain whether it has improved the management of transfers in.” Source location 2019-0345-Response-by-Guys-and-St-Thomas-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit the consultant-of-the-week system to assess whether it improves transfer management.
Verbatim wording from the response “In April 2019, to improve the Thoracic Surgery Service, the referrals system was changed to a “consultant of the week” system. A single consultant and their team take responsibility for the triage and management of all referrals for the week, with the aim of improving the prioritisation of patients for transfer in to the Thoracic Surgery Service. The “consultant of the week” system will be audited to ascertain whether it has improved the management of transfers in.” Source location 2019-0345-Response-by-Guys-and-St-Thomas-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase Guy’s Hospital thoracic surgery bed capacity by switching wards and completing necessary estate works.
Verbatim wording from the response “The Trust is looking towards an electronic referral system that allows local specialist services to manage their own tertiary referrals and gives the Site Management Team an overview of the current waiting list. In addition, the Trust Operational Board is currently looking to increase the number of beds on the Guy’s Hospital site for Thoracic Surgery patients. This will be achieved through switching the wards on which services are provided and undertaking the necessary estate works. It is expected that the increased capacity will be available during the first quarter of 2020.” Source location 2019-0345-Response-by-Guys-and-St-Thomas-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transfer bed allocation and urgent thoracic surgery transfers to the Site Management Team using a three-level urgency and transfer process.
Verbatim wording from the response “In October 2019, to mitigate the risk of capacity issues impacting on transfers, the Directorate Management Team transferred the management of the Thoracic Surgery Service’s beds and urgent transfer process to the Site Management Team. This change aligned the Thoracic Surgery Service with other services across the Trust. The process, set out in the UTCI Flow Chart (appendix 1), enables the Thoracic Surgery Service to triage its patients into three categories (1) Admission not urgent, (2) Urgent – Needs admission within 48 hours and (3) Urgent – Needs admission immediately and for the appropriate transfer to be arranged.” Source location 2019-0345-Response-by-Guys-and-St-Thomas-NHS-Trust
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24 Sep 2019 Daniel Williams · Prevention of Future Deaths report Inner South London
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Concerns raised 2 Failure to deliver the fundamentals of care on a general gastrointestinal ward View source Failure to extend C. difficile case investigations to transferring wards View source
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AI-generated summary
Daniel Williams · 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
Daniel Williams died at St Thomas' Hospital on 26 November 2017 after developing complications of gastrointestinal surgery, including infection and sepsis, against a background of significant medical complexity. Concerns included deficient nursing care on a general gastrointestinal ward and a potential limitation in the investigation of Clostridium difficile cases when a patient had recently been transferred from another ward.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Guy'S and St Thomas' NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to deliver the fundamentals of care on a general gastrointestinal ward
Wider context from the report “2) The nursing care which Mr Williams received on this general gastrointestinal (GI) ward was found - by an internal Trust investigation which took place sometime after Mr Williams' death following a request by myself - to be "deficient in delivering the fundamentals of 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 Guy'S and St Thomas' NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to extend C. difficile case investigations to transferring wards
Wider context from the report “4) Although I found at inquest that the presence of c-diff was not relevant to how Mr Williams ultimately came by his death I have residual concerns with the potential under investigation of c-diff cases within the Trust from what I was told about the process which is triggered on discovering the presence of c-diff.
5) At Mr Williams' inquest I was told that c-diff infection is a potentially fatal infection. Consequently it is a regulatory requirement that hospitals trusts carry out a clinical case review whenever c-diff is found in order to determine whether it was linked to any "lapses of care" in the care and treatment of the patients.
6) I was told that what should happen following the collection of a positive sample is that an alert is sent to the infection control nurse when this distributes the mandatory infection control data collection form to, inter alia, the ward on which the patient is currently. That ward - and that ward alone - then investigates focussed on identifying "any significant deviations from best practice..." including in the following categories: deficiency in environmental cleaning, deficiency in hand hygiene and / or deficiency in antimicrobial stewardship. What is not done however, is if the respective patient has recently been transferred from another ward, the investigation does not extend to the conditions on the transferring ward .
7) In this case it was the transferring ward where there were found to have been failings in delivering the fundamentals of care and about which the family had raised significant concerns at the time. The only reason these failures were highlighted was that an investigation was undertaken following a pre-inquest review on 26 September 2018 at which the family raised concerns that Mr Williams had died as a result of a c-diff infection contracted as a result of poor nursing care. The extent of the Trust's investigation was limited as it was conducted significantly after the event.
” 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 Revise the C. difficile investigation process to assess and investigate relevant prior wards occupied within the preceding seven days.
Verbatim wording from the response “The Trust’s c-diff Action Group, under the chairmanship of Dr Simon Goldenberg, has reviewed the Trust’s c-diff investigation process as a result of Mr Williams’ death.” Source location 2019-0309-Response-by-Guys-and-St-Thomas-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed Fundamentals of Care standards through staff training, induction education and competency assessments covering core care, hygiene, infection prevention, fluids and nutrition.
Verbatim wording from the response “The Trust launched its Fundamentals of Care standards (‘the standards’) in April 2018. Following its inception, members of staff at the Trust have received training on the standards and I am satisfied that they are now embedded into the nursing practice on both Page Ward and Northumberland Ward. All new members of staff at the Trust receive education and training in relation to the standards as part of the Trust’s specialised induction programme. Staff are also required to complete a competency assessment document which includes assessments around hygiene; infection prevention and control; fluid management and nutrition. All nursing staff on the GI unit, as part of their ongoing development, are required to complete competencies which include getting the basics of the core correct and delivering excellent fundamental care.” Source location 2019-0309-Response-by-Guys-and-St-Thomas-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct weekly quality rounds across Gastro Medicine and Surgical Directorate wards to review patient safety and experience and escalate staff concerns.
Verbatim wording from the response “The Trust’s Directorate Management Team (‘DMT’) is committed to ensuring that fundamental care is the cornerstone of our practice; this is not just within nursing care but also across the wider multi-disciplinary team. Quality rounds take place weekly which are led by the Clinical Director and Head of Nursing; these endeavour to review both patient safety and patient experience on all wards in the Gastro Medicine and Surgical (‘GMS’) Directorate. The Trust has found that engaging with the clinical teams in this way enables its DMT to clearly interact with staff members and offers a forum for staff to voice any concerns they hold. In addition, it allows the Trust’s DMT to support staff with challenging situations (e.g. an operational issue, a staffing issue or a patient with complex needs) that require escalation.” Source location 2019-0309-Response-by-Guys-and-St-Thomas-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase Page Ward staffing by one whole-time-equivalent senior nursing assistant on both day and night shifts.
Verbatim wording from the response “A Trust wide establishment review takes place twice a year to determine whether the current staffing levels meet the needs of our service. Workforce Key Performance Indicators are considered (such as: vacancies, sickness and statutory and mandatory training) as well as planned staffing numbers against actual staff numbers. The workforce establishment review in 2018 highlighted the need to increase the numbers of senior nursing assistants on Page Ward in order to support the effective delivery of fundamental care. These posts have now been recruited into and the staff are now in place on Page Ward. Staffing has therefore increased by 1 whole time equivalent senior nursing assistant on both the day and the night shift on Page Ward.” Source location 2019-0309-Response-by-Guys-and-St-Thomas-NHS-Trust
Open published response
Concerns raised 3 Uncertainty in Holter interpretations and identification of NSVTs on traces View source Failure to view, acknowledge and respond to direct-access patient communications View source Lack of checks to ensure review of requested investigations and appropriate action in line with guidelines View source
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AI-generated summary
Mr Harold Chapman · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Harold Chapman, who had hypertrophic cardiomyopathy, died on 14 June 2016 after developing a significant cardiac arrhythmia. The inquest found that non-sustained ventricular tachycardia identified in 2015 was not reviewed promptly, delaying consideration of an implantable cardioverter defibrillator. A further concern was that patient emails sent to consultants were often not viewed or acted upon, with no response provided.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Guy'S and St Thomas' NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Uncertainty in Holter interpretations and identification of NSVTs on traces
Wider context from the report “(3) There was also a concern in respect of the holter interpretations and the presence or otherwise of NSVTs on the traces. Barts NHS Trust have instigated a new introduction and training regime for its specialist clinical fellows in the interpretation of holter readings.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Guy'S and St Thomas' NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to view, acknowledge and respond to direct-access patient communications
Wider context from the report “During the course of the inquest, the evidence revealed during his dealings with the Barts NHS Trust and, more specifically the lead consultants, emails were passed by Mr Chapman to the consultants. It became clear during the inquest that those emails were often not viewed and/or acted upon and as a result no response was received by the patient .
It is fully appreciated that consultants are busy with their clinical responsibilities covering wards, clinics and on-calls.
However, if contact details are provided for ‘direct access’ to individual doctors/consultants, it seems obligatory that those should be viewed, acknowledged and patients responded to .
Patient contact with medical professionals, not just hospital related, is an important part of modern medical practice.
Whilst this is a huge task, it would seem possible to come up with either National or local guidelines in respect of the use of all forms of communication between patients and their clinician (covering phone and emails).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Guy'S and St Thomas' NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of checks to ensure review of requested investigations and appropriate action in line with guidelines
Wider context from the report “(1) the consultant responsible for Mr Chapman’s care in August and November 2015 was based, at the time, at Barts NHS Trust and is now employed by the Brompton. The consultant was responsible for reviewing the investigations that he (and other members of his team in their absence) had requested.
(2) There appeared to be no check mechanisms in place to ensure that this was done and appropriate action taken in line with the Guidelines..
” 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 Report Holter recordings through trained physiology technicians, communicate concerning findings to referring consultants, and upload reports to electronic patient records.
Verbatim wording from the response “The RBHT Sudden Cardiac Death (SCD) Service is reviewing compliance with the European Society of Cardiology (ESC) 2014 guidelines on diagnosis and management of hypertrophic cardiomyopathy. The RBHT Cardiomyopathy service (which includes SCD patients) is consultant delivered with a specialist consultant present in every clinic. Clinic letters have a standardised format including risk stratification for SCD risk (calculated using the SCD calculator) which includes regular Holter rhythm monitoring as per the ESC 2014 guidelines. All Holter tapes are reported by trained cardiac physiology technicians and findings of concern are communicated directly to the referring consultant by phone or email (if requested by a fellow). Holter monitor reports are uploaded into the electronic patient record (EPR) along with all other investigation results.” Source location 2017-0377-Response-by-Royal-Brompton-Harefield-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider producing local clinician guidance on patient email and text communication based on NHS England guidance.
Verbatim wording from the response “RBHT is in the process of exploring current practice in relation to email correspondence between clinicians and patients and, pending production of any national guidelines from the Department of Health, will consider production of local guidance to clinicians based on the NHS England Accessible Information Standard ‘Using email and text messaging for communicating with patients- guidance from the Information Governance team at NHS England’ (May 2016).” Source location 2017-0377-Response-by-Royal-Brompton-Harefield-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore current practice for email correspondence between clinicians and patients.
Verbatim wording from the response “RBHT is in the process of exploring current practice in relation to email correspondence between clinicians and patients and, pending production of any national guidelines from the Department of Health, will consider production of local guidance to clinicians based on the NHS England Accessible Information Standard ‘Using email and text messaging for communicating with patients- guidance from the Information Governance team at NHS England’ (May 2016).” Source location 2017-0377-Response-by-Royal-Brompton-Harefield-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review compliance with ESC 2014 guidelines for diagnosing and managing hypertrophic cardiomyopathy.
Verbatim wording from the response “The RBHT Sudden Cardiac Death (SCD) Service is reviewing compliance with the European Society of Cardiology (ESC) 2014 guidelines on diagnosis and management of hypertrophic cardiomyopathy. The RBHT Cardiomyopathy service (which includes SCD patients) is consultant delivered with a specialist consultant present in every clinic. Clinic letters have a standardised format including risk stratification for SCD risk (calculated using the SCD calculator) which includes regular Holter rhythm monitoring as per the ESC 2014 guidelines. All Holter tapes are reported by trained cardiac physiology technicians and findings of concern are communicated directly to the referring consultant by phone or email (if requested by a fellow). Holter monitor reports are uploaded into the electronic patient record (EPR) along with all other investigation results.” Source location 2017-0377-Response-by-Royal-Brompton-Harefield-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide regular Holter-interpretation training for cardiomyopathy fellows through multidisciplinary meetings and consultant-supervised clinics.
Verbatim wording from the response “At RBHT all Holter monitor traces are interpreted and reported by trained electrophysiology technicians. Training for cardiomyopathy subspecialty fellows in Holter monitor interpretation is provided at regular MDT meetings and consultant supervised clinics, in addition to standard training for general cardiology trainees in rhythm interpretation.” Source location 2017-0377-Response-by-Royal-Brompton-Harefield-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Multidisciplinary discussion is not required before ICD implantation because urgent cases can be referred directly to an implanting consultant.
Verbatim wording from the response “Abnormal Holter results are regularly discussed at MDT meetings. MDT discussion is not a pre-requisite for ICD implant at RBHT and urgent cases are referred directly to an implanting consultant who will list the patient as appropriate. Where MDT discussion is required (complex patients or those not meeting all criteria) this occurs within 2 weeks. The non-urgent waiting time for ICD implant from time of agreement to implant is of the order of 8-12 weeks. As a result of the PFD notice the inherited cardiac conditions care group are developing a standard operating procedure for notification of potentially significant arrhythmias.” Source location 2017-0377-Response-by-Royal-Brompton-Harefield-NHS-Trust
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17 Sep 2015 Lee Mark Anthony Bates · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Lack of guidance for psychiatric staff on CPAP, sedative medication risks and oximetry in OSA View source Failure to establish monitoring arrangements for high-risk sedated patients with OSA View source Failure to establish dialogue between specialist physicians and psychiatrists about managing OSA risks 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.
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AI-generated summary
Lee Mark Anthony Bates · 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
Lee Mark Anthony Bates died at 01.18 on 24 February 2014 in Cambian Churchill London Clinic after ingesting a potentially fatal overdose of Zopiclone in conjunction with benzodiazepines while under one-to-one eyesight observation. The principal concerns were inadequate staff training in one-to-one observation and insufficient coordination between psychiatric and sleep-apnoea specialists about CPAP use, sedative medication risks, and monitoring of patients with severe obstructive sleep apnoea.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Guy'S and St Thomas' NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for psychiatric staff on CPAP, sedative medication risks and oximetry in OSA
Wider context from the report “The court heard that neither the psychiatrists sought advice from the sleep apnoea clinic nor did the clinic inform the psychiatrists of the importance of using CPAP, the risks of not doing so and the risks of sedative medication especially if not using it and the desirability of oximetry . ████████ director of the hospital, said that there was no guidance from GSTT about the use of the CPAP machine , of which psychiatric staff would not be familiar. He presumed that none of the psychiatrists sought guidance about medication, observation or use of the machine in a patient with severe sleep apnoea, as they did not see the need. He expected that the sleep clinic would provide any advice that psychiatrists needed in managing the OSA in a psychiatric unit.
████████ consultant psychiatrist at Cambian, acknowledged that there were risks of death to people with severe OSA given drugs and then not taking CPAP. Physical health care needs were advised by GPs. He said that psychiatric staff did not know about the importance of CPAP, nor whether introduction of a drug required monitoring . There is the facility to use pulse oximetry in the hospital, but the implications, if it were to be used in all OSA patients, would need to be considered. There are many OSA patients in Cambian.
It is clear that there is an on going risk of avoidable death in patients with OSA in Cambian Churchill hospital (especially if severe and associated with morbid obesity), Although this risk is reduced by use of CPAP machine and increased by use of sedative drugs, and may be mitigated by use of oximetry, such measures require dialogue between specialist physicians and psychiatrists and might require special provision for monitoring of patients that are high risk and require sedation. Neither hospital has addressed how this dialogue is to be instigated when required, nor how these risks should be addressed; reliance on GP advice seeming to be insufficient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Guy'S and St Thomas' NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish monitoring arrangements for high-risk sedated patients with OSA
Wider context from the report “The court heard that neither the psychiatrists sought advice from the sleep apnoea clinic nor did the clinic inform the psychiatrists of the importance of using CPAP, the risks of not doing so and the risks of sedative medication especially if not using it and the desirability of oximetry. ████████ director of the hospital, said that there was no guidance from GSTT about the use of the CPAP machine, of which psychiatric staff would not be familiar. He presumed that none of the psychiatrists sought guidance about medication, observation or use of the machine in a patient with severe sleep apnoea, as they did not see the need. He expected that the sleep clinic would provide any advice that psychiatrists needed in managing the OSA in a psychiatric unit.
████████ consultant psychiatrist at Cambian, acknowledged that there were risks of death to people with severe OSA given drugs and then not taking CPAP. Physical health care needs were advised by GPs. He said that psychiatric staff did not know about the importance of CPAP, nor whether introduction of a drug required monitoring . There is the facility to use pulse oximetry in the hospital, but the implications, if it were to be used in all OSA patients, would need to be considered. There are many OSA patients in Cambian.
It is clear that there is an on going risk of avoidable death in patients with OSA in Cambian Churchill hospital (especially if severe and associated with morbid obesity), Although this risk is reduced by use of CPAP machine and increased by use of sedative drugs, and may be mitigated by use of oximetry, such measures require dialogue between specialist physicians and psychiatrists and might require special provision for monitoring of patients that are high risk and require sedation . Neither hospital has addressed how this dialogue is to be instigated when required, nor how these risks should be addressed ; reliance on GP advice seeming to be insufficient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Guy'S and St Thomas' NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish dialogue between specialist physicians and psychiatrists about managing OSA risks
Wider context from the report “The court heard that neither the psychiatrists sought advice from the sleep apnoea clinic nor did the clinic inform the psychiatrists of the importance of using CPAP, the risks of not doing so and the risks of sedative medication especially if not using it and the desirability of oximetry. ████████ director of the hospital, said that there was no guidance from GSTT about the use of the CPAP machine, of which psychiatric staff would not be familiar. He presumed that none of the psychiatrists sought guidance about medication, observation or use of the machine in a patient with severe sleep apnoea, as they did not see the need. He expected that the sleep clinic would provide any advice that psychiatrists needed in managing the OSA in a psychiatric unit.
████████ consultant psychiatrist at Cambian, acknowledged that there were risks of death to people with severe OSA given drugs and then not taking CPAP. Physical health care needs were advised by GPs. He said that psychiatric staff did not know about the importance of CPAP, nor whether introduction of a drug required monitoring. There is the facility to use pulse oximetry in the hospital, but the implications, if it were to be used in all OSA patients, would need to be considered. There are many OSA patients in Cambian.
It is clear that there is an on going risk of avoidable death in patients with OSA in Cambian Churchill hospital (especially if severe and associated with morbid obesity), Although this risk is reduced by use of CPAP machine and increased by use of sedative drugs, and may be mitigated by use of oximetry, such measures require dialogue between specialist physicians and psychiatrists and might require special provision for monitoring of patients that are high risk and require sedation. Neither hospital has addressed how this dialogue is to be instigated when required , nor how these risks should be addressed; reliance on GP advice seeming to be insufficient.
” Open source report
Concerns raised 3 Lack of microbiological sampling from open blister wounds View source Failure to consider intravenous antibiotics View source Failure to consider alternative effective diagnoses or treatments View source
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Each statement is shown once, even when linked to more than one concern.
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Peter Jeffrey · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Jeffrey collapsed at home and died on 10 February 2013 after developing a swollen, infected left leg and foot. The report raised concerns that, after scans did not reveal DVT, no effective alternative diagnosis or treatment was considered, and that the open blister was not cultured or swabbed and intravenous antibiotics were not considered. The inquest concluded that the left foot ulcer was not tested and consequently went untreated.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Guy'S and St Thomas' NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of microbiological sampling from open blister wounds
Wider context from the report “2. No culture was taken for testing from the open blister which was full of pus .
3. No swab was taken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Guy'S and St Thomas' NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider intravenous antibiotics
Wider context from the report “4. No intravenous antibiotics were considered .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Guy'S and St Thomas' NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider alternative effective diagnoses or treatments
Wider context from the report “1. The scans did not reveal DVT and no alternative effective diagnosis or treatment was considered .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The records show no open blister or pus on 17 August 2012, so there was nothing to swab.
Verbatim wording from the response “Please see above for the primary detail. We agree that in the event of an ‘open blister’ being noted, which included pus or signs of infection, it would be appropriate to expect the necessary organisms to be collected on a swab and then grown and tested in the laboratory.” Source location 2013-0313-Response-by-Guys-St-Thomas-NHS-Foundation-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation If cellulitis persisted, intravenous antibiotics would require referral by the GP to a suitable hospital.
Verbatim wording from the response “In the event the condition did not resolve after the 2 week course of antibiotics, we agree that IV antibiotics could have been considered, however at this stage Mr Jeffery would have been under the care of his GP, and a referral to a suitable hospital to receive the IV intervention, would have been necessary. Mr Jeffery was not seen at this trust after 17 August 2012.” Source location 2013-0313-Response-by-Guys-St-Thomas-NHS-Foundation-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No other particular action is intended regarding the diagnostic aspects of this case at this time.
Verbatim wording from the response “We are not intending to take any other particular action arising from the diagnostic aspects of this case at this time, but remain happy to receive further information from HM Assistant Coroner as to why this is a concern, if this course of action is not considered to be acceptable.” Source location 2013-0313-Response-by-Guys-St-Thomas-NHS-Foundation-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust’s DVT protocol, diagnostic review, and oral antibiotics were appropriate responses to the working diagnosis of cellulitis.
Verbatim wording from the response “On the basis of the above information, and despite being aware of the subsequent cause of death 6 months after that intervention, we have been unable to identify what alternative clinical approach might have been adopted for Mr Jeffery in August 2012. The treatment followed the Trust’s DVT protocol, with 2 negative scans followed by referral to medics to review for alternative diagnoses. This took place on 17 August 2012, with a working diagnosis of cellulitis being given, and a 2 week course of antibiotics, which would ordinarily be expected to deliver effective treatment.” Source location 2013-0313-Response-by-Guys-St-Thomas-NHS-Foundation-Trust
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Addressed to Royal Brompton & Harefield NHS Foundation Trust, now represented here by Guy'S and St Thomas' NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations