Concerns raised 3 Failure of ED discharge summaries to clearly identify diagnoses and actions expected from GPs View source Failure of clozapine services to provide annual physical-health blood testing View source Failure to establish RCPath guidance for telephone escalation of raised triglyceride levels View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sebastian Harry DANIELS · 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
Sebastian Harry Daniels, who had paranoid schizophrenia and was treated with clozapine, developed severe hypertriglyceridemia and necrotising pancreatitis before dying from multiple organ failure on 4 July 2021. Concerns included the failure to escalate abnormal triglyceride results, unclear communication of required GP actions in hospital discharge summaries, delays in addressing identified deficiencies, and the requirement for patients taking clozapine to attend separate appointments for some blood tests.
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 Hampshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ED discharge summaries to clearly identify diagnoses and actions expected from GPs
Wider context from the report “2. The RCA report identified that the format of discharge summaries provided to GPs by the ED department needed to be reviewed to ensure that actions to be undertaken by GPs were clearly identified . The results of this were to be audited.
Following the inquest I was provided with an audit report. This report dated 13/9/21 revealed that the computer system could not be altered as had been hoped and therefore a change of practice was introduced instead. This required clinicians to document actions in a free text section with appropriate flagging for GPs. 20 cases were audited and only half met the standard national guidance and 8 lacked a clear diagnosis & details of what was expected from GPs .
Hampshire Hospital Trust have informed me that further actions are being taken to address these deficiencies. However as it is now a year since the RCA report was prepared and over 2 years since Mr Daniel’s death I am concerned that this action is not being taken swiftly given the risks to patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clozapine services to provide annual physical-health blood testing
Wider context from the report “3. In relation to the blood tests required under the clozapine guidelines I was informed that Southern Health take the monthly blood tests and run these in the clozapine clinic. However the blood tests required of the annual physical health checks are not taken by the Southern Health staff but rather patients are required to attend phlebotomy services elsewhere for the blood to be taken .
I heard evidence during the inquest that Mr Daniels had missed some of these blood test appointments which meant his full tests were not carried out when expected. Clozapine is prescribed only to patients suffering from an enduring mental health condition for whom other medication has not been effective which indicates that they may be at risk of having difficulty managing appointments.
I heard evidence from the consultant psychiatrist responsible for Mr Daniel’s treatment that they were not permitted to take the blood samples and submit them to the local laboratory for testing . I was informed that the Southern Health staff had requested to be able to do this to avoid the patient having to attend another appointment.
I have reviewed further information provided after the inquest by the Clinical Director of Southern Health. She has explained that they lack the facilities to complete the full blood tests and the lack the resources to take and deliver samples to the laboratories ; noting that no community mental health teams in their trust routinely provide phlebotomy services. She has advised that they are focussed on better communication with primary care and assertive outreach where necessary.
I remain concerned that patients on high risk medication, who by the nature of their mental health condition may struggle to attend appointments, are required to arrange or attend separate blood tests. I note that clozapine clinic staff also blood monthly and that the physical health reviews are carried out by doctors all of whom should be capable of taking a blood sample for submission to a laboratory.
” 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 Hampshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish RCPath guidance for telephone escalation of raised triglyceride levels
Wider context from the report “1 The abnormal triglyceride levels in Mr Daniel’s blood, whilst reported by the lab, were not escalated by telephone as this was not required by the hospital procedure at the time.
I am pleased to note that Hampshire Hospitals Trust have updated their procedures to include telephone escalation of raised triglyceride levels.
However the RCA report indicated that the findings in this case should be shared with the Royal College of Pathologists with a request that raised triglyceride levels be added to the RCPath guidelines for telephone action . In information received after the inquest the Hampshire Hospitals Trust advised that they could not tell me whether or not this action has been undertaken .
” 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 Update the junior doctors’ induction programme to include the revised discharge-process requirements.
Verbatim wording from the response “ED clinicians have also been notified that they are required to continue to document significant findings and matters requiring GP attention, under a separate heading within the GP free text notes box, on the Patient First discharge summary. It was felt that compliance of this, underpinned with documented audit, was likely limited due to the turnover of trainee doctors. In order to ensure that all staff remain aware of this requirement the Trust is in the process of updating its junior doctors induction program to include the above changes in the discharge process. This will take effect from the next induction taking place on 6 December 2023.” Source location Response from Hampshire Hospitals NHS Foundation Trust
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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 Require ED clinicians to document significant findings and matters requiring GP attention under a separate heading in discharge summaries.
Verbatim wording from the response “ED clinicians have also been notified that they are required to continue to document significant findings and matters requiring GP attention, under a separate heading within the GP free text notes box, on the Patient First discharge summary. It was felt that compliance of this, underpinned with documented audit, was likely limited due to the turnover of trainee doctors. In order to ensure that all staff remain aware of this requirement the Trust is in the process of updating its junior doctors induction program to include the above changes in the discharge process. This will take effect from the next induction taking place on 6 December 2023.” Source location Response from Hampshire Hospitals NHS Foundation Trust
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 Update hospital procedures to require telephone escalation of raised triglyceride levels.
Verbatim wording from the response “1. “The abnormal triglyceride levels in Mr Daniel’s blood, whilst reported by the lab, were not escalated by telephone as this was not required by the hospital procedure at the time.
I am pleased to note that Hampshire Hospitals Trust have updated their procedures to include telephone escalation of raised triglyceride levels.
However the RCA report indicated that the findings in this case should be shared with the Royal College of Pathologists with a request that raised triglyceride levels be added to the RCPPath guidelines for telephone action. In information received after the inquest Hampshire Hospitals Trust advised that they could not tell me whether or not this action has been undertaken.”” Source location Response from Hampshire Hospitals NHS Foundation Trust
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 Re-audit a random sample of discharge letters at three and six months to monitor the impact of the changes.
Verbatim wording from the response “In order to monitor the impact of these actions the Trust will re-audit a random sample of discharge letters at three and six months.” Source location Response from Hampshire Hospitals NHS Foundation Trust
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 Sharing the RCA findings with the Royal College was allocated to the Hampshire and Isle of Wight Integrated Care Board, not the Trust.
Verbatim wording from the response “Within the multiagency RCA investigation report this action was allocated to our colleagues at the Hampshire and Isle of Wight Integrated Care Board (ICB) and not to our Trust.” Source location Response from Hampshire Hospitals NHS Foundation Trust
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 Whether raised triglyceride levels are added to Royal College telephone-action guidelines is a decision for the Royal College, not the Trust.
Verbatim wording from the response “Unfortunately we are unable to comment any further on this point, as whether raised triglyceride levels are added to the Royal College guidelines for telephone action is a decision for the Royal College and not the Trust. We can, however confirm that the NHS, by way of the ICB, did share the findings with the Royal College and request that the guidelines were updated.” Source location Response from Hampshire Hospitals NHS Foundation Trust
Open published response
Concerns raised 3 Failure to share information between alcohol liaison and inclusion services View source Failure to provide follow-up after emergency department admissions for alcohol-related presentations View source Lack of a coordinated plan to treat alcohol dependence View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Nigel Malloy · 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
Nigel Malloy fell from a second-floor window on 29 October 2017 while intoxicated with alcohol, suffered severe head injuries, and died in hospital two days later. He was alcohol dependent and had depressive symptoms, with previous similar falls and multiple hospital admissions, but concerns were raised that there was no information sharing or coordinated treatment plan between the relevant alcohol-support services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share information between alcohol liaison and inclusion services
Wider context from the report “The Deceased was alcohol dependant and suffered depressive symptoms. On 22 May 2017 he fell from a window in circumstances very similar to those on 29 October 2017 and on that occasion suffered head injuries and was taken to Southampton General Hospital. After this fall he was regularly drinking excess alcohol leading to multiple admissions to the Emergency Department at Royal Hampshire County Hospital Winchester operated by Hampshire Hospitals NHS Foundation Trust (HHFT), but was then discharged once sober without any follow up. On 22 September 2017 he referred himself to the Inclusion Service provided by South Staffordshire & Shropshire NHS Foundation Trust (SSSFT) and started to receive some assistance. On 16 October 2017 the deceased sustained a fall in the street and was taken to Winchester hospital for treatment of his head wound but discharged the same day. There was no sharing of information between the Alcohol Liaison service provided by HHFT and the Inclusion Service provided by SSSFT or coordinated plan to treat his alcohol dependence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide follow-up after emergency department admissions for alcohol-related presentations
Wider context from the report “The Deceased was alcohol dependant and suffered depressive symptoms. On 22 May 2017 he fell from a window in circumstances very similar to those on 29 October 2017 and on that occasion suffered head injuries and was taken to Southampton General Hospital. After this fall he was regularly drinking excess alcohol leading to multiple admissions to the Emergency Department at Royal Hampshire County Hospital Winchester operated by Hampshire Hospitals NHS Foundation Trust (HHFT), but was then discharged once sober without any follow up . On 22 September 2017 he referred himself to the Inclusion Service provided by South Staffordshire & Shropshire NHS Foundation Trust (SSSFT) and started to receive some assistance. On 16 October 2017 the deceased sustained a fall in the street and was taken to Winchester hospital for treatment of his head wound but discharged the same day. There was no sharing of information between the Alcohol Liaison service provided by HHFT and the Inclusion Service provided by SSSFT or coordinated plan to treat his alcohol dependence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a coordinated plan to treat alcohol dependence
Wider context from the report “The Deceased was alcohol dependant and suffered depressive symptoms. On 22 May 2017 he fell from a window in circumstances very similar to those on 29 October 2017 and on that occasion suffered head injuries and was taken to Southampton General Hospital. After this fall he was regularly drinking excess alcohol leading to multiple admissions to the Emergency Department at Royal Hampshire County Hospital Winchester operated by Hampshire Hospitals NHS Foundation Trust (HHFT), but was then discharged once sober without any follow up. On 22 September 2017 he referred himself to the Inclusion Service provided by South Staffordshire & Shropshire NHS Foundation Trust (SSSFT) and started to receive some assistance. On 16 October 2017 the deceased sustained a fall in the street and was taken to Winchester hospital for treatment of his head wound but discharged the same day. There was no sharing of information between the Alcohol Liaison service provided by HHFT and the Inclusion Service provided by SSSFT or coordinated plan to treat his alcohol dependence.
” 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 Maintain a 24-hour referral service and dedicated pathway with the Inclusion Service.
Verbatim wording from the response “• A 24 hour referral service and dedicated pathway with Inclusion” Source location 2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
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 Participate in a monthly multi-provider High Intensity User Group to identify further support for frequent attenders.
Verbatim wording from the response “• Monthly High Intensity User Group involving multiple providers to discuss whether there is any further support which can be provided to high intensity users such as Mr Malloy” Source location 2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
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 Maintain telephone and onsite liaison with Inclusion regarding referrals and referred patients receiving inpatient care.
Verbatim wording from the response “• Regular telephone liaison between Inclusion and the Trust when one of their users is an inpatient or in relation to referrals” Source location 2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
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 Provide alcohol-service inpatient access through weekly and arranged ad hoc Inclusion inreach.
Verbatim wording from the response “• At the time of Mr Malloy’s admissions to the Trust, Inclusion were running a weekly inreach service on a Sunday.” Source location 2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
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 referral, liaison, follow-up and high-intensity-user arrangements are considered sufficient to address the reported concerns.
Verbatim wording from the response “As per our response to point 2 above, the Trust made the initial referral to Inclusion on 21.09.17 and subsequently liaised with them to arrange Mr Malloy’s first attendance and ensure that Mr Malloy had attended as planned.” Source location 2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
Open published response
26 Jan 2018 Joan Elizabeth Betteridge · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 2 Failure to correctly classify radiology review requests from discharged emergency department patients View source Failure to ensure timely making and progression of X-ray requests View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Joan Elizabeth Betteridge · 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
Joan Elizabeth Betteridge, aged 88, died during surgery for a displaced fractured neck of femur after a series of falls and delays in identifying the fracture. She developed bradycardia shortly after bone cement was inserted and was pronounced dead despite resuscitation attempts; the post-mortem identified bone cement implantation syndrome, with ischaemic heart disease as a contributory condition. The concerns included delays in requesting and progressing repeat X-rays and a radiology review system that did not identify the fracture promptly.
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 Hampshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly classify radiology review requests from discharged emergency department patients
Wider context from the report “I heard from ████████, Director of Surgical Services, that many changes have been made to date and some are still ongoing such as planned future audits. He also confirmed that when an acute patient like Mrs Betteridge is discharged from ED back home for community care, the radiology review is the fall back system. Priority is given to ED and GP referrals and the reason there was a delay in this case from 31 May until 12 June was that the request for a review was registered as an inpatient referral not an ED referral. Why that happened was not known but clearly Mrs Betteridge was never an inpatient on 31 May.
” 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 Hampshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely making and progression of X-ray requests
Wider context from the report “I heard evidence that ████████ intended to request a repeat X-ray on 1 June but nothing happened until the physiotherapist queried this with a different GP in the same surgery. This raises concerns either that the request was not made or if it was made then it was not progressed in a timely fashion. A further request was made on 7 June and took place on 9 June, two days later.
” 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 Educate emergency-department clinicians on correctly recording X-ray request locations in ICE.
Verbatim wording from the response “████████ Clinical Lead for Emergency Medicine, has also confirmed that the clinicians working in the emergency department have been educated on the importance of correctly recording the location of the requests, since this directly affects the timeframes for radiological review and reporting of images.” Source location 2018-0026-Response-by-Hampshire-NHS-Trust
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 Change the default ICE request location on the affected emergency-department computer to the emergency department.
Verbatim wording from the response “The default location on that computer has since been changed to the emergency department. I am pleased to confirm that the other computers in the emergency department that are used for accessing ICE were already set to the correct default location.” Source location 2018-0026-Response-by-Hampshire-NHS-Trust
Open published response
11 Jul 2017 Mark William Berry · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 3 Failure to convey address information from private ambulance services to SCAS control room before staff go off duty View source Failure to include basic location details in ambulance-to-hospital handovers View source Failure to make timely and procedurally clear police notifications in appropriate deaths 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
Mark William Berry · 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
Mark William Berry suffered a cardiac arrest after apparently taking morphine or heroin and pregabalin, and was declared dead in hospital. The medical cause of death was recorded as morphine toxicity. Concerns included delays in notifying police, incomplete handover information about the address where he was found, and communication of information from a private ambulance service to the control room.
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 Hampshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to convey address information from private ambulance services to SCAS control room before staff go off duty
Wider context from the report “3. Finally, the lack of an address may require further consideration of how basic but potentially important data is conveyed to SCAS control room from a private ambulance service especially before staff go off duty and thereby avoiding delay.
” 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 Hampshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include basic location details in ambulance-to-hospital handovers
Wider context from the report “2. Although I was not shown the handover paperwork from the ambulance technicians to hospital staff, the lack of basic detail such as the address where Mr Berry was found may mean that handover procedures should be revisited especially if there is a private ambulance service involved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make timely and procedurally clear police notifications in appropriate deaths
Wider context from the report “1. Hospital staff did not contact police in what appeared to be a suspicious and unnatural death for several hours. Further, I was told there appeared to be confusion about the correct procedure with regards to notifying police . This suggests a possible need to revisit who, when and how hospital staff contact the police both before and after death in appropriate cases.
” 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