20 Aug 2025 Charles Andrew STONLEY · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 3 Severe shortage of beds in mental health facilities View source Lack of legal powers for mental health patients in hospital Emergency Departments View source Limited resources for mental health patients in hospital Emergency Departments 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
Charles Andrew STONLEY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Charles Andrew Stonley, who had severe depression with psychotic features, attended hospital with suicidal ideations and psychotic and paranoid symptoms while awaiting a mental health bed. After repeatedly leaving the Emergency Department, he was found deceased hanging in a wooded area. The report raises concerns about limited legal powers and resources for managing mental health patients in Emergency Departments and shortages of mental health beds, which can leave vulnerable patients at increased risk of self-harm and death.
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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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Severe shortage of beds in mental health facilities
Wider context from the report “2. The severe shortage and availability of beds in mental health facilities resulting in vulnerable patients being left in the Emergency Department for days increasing the risk of self harm and death.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Lack of legal powers for mental health patients in hospital Emergency Departments
Wider context from the report “1. The legal powers and resources available for mental health patients in the Emergency Department of Hospitals is limited and as such detrimental to those attending Accident and Emergency Departments when suffering from a mental health crisis.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Limited resources for mental health patients in hospital Emergency Departments
Wider context from the report “1. The legal powers and resources available for mental health patients in the Emergency Department of Hospitals is limited and as such detrimental to those attending Accident and Emergency Departments when suffering from a mental health crisis.
” 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 Launch an investigation into care for patients in mental health crisis in emergency departments, including staffing, environment and admission or discharge decisions.
Verbatim wording from the response “On 26 August, we approved two new HSSIB investigations into mental health crisis care. These investigations will help to address key areas of concern highlighted in your report. These investigations are:” Source location 2025-0432 - Response from Health Services Safety Investigations Body (HSSIB)
Open published response
4 Aug 2025 Tracey Ostler · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 13 Unclear legal authority for preventing psychiatric patients leaving the emergency department View source Unavailability of appropriately trained mental health nurses for acute psychiatric patients View source Unclear ultimate clinical responsibility for psychiatric patients in the emergency department View source Compromised emergency department capacity to meet physically ill patients' needs View source Failure to provide appropriate multidisciplinary psychiatric ward-based care View source Lack of psychiatric hospital beds resulting in prolonged emergency department detention View source Failure to undertake thorough mental capacity assessments for life-threatening treatment decisions View source Failure to provide lawful Mental Health Act detention safeguards and Responsible Clinician oversight View source Inadequate paramedic training for mental capacity assessments View source Inadequate and unavailable protocol for capacity assessments in life-threatening circumstances View source Lack of a system for joint ambulance and mental health emergency plans View source Failure to provide frontline paramedics with vital mental health risk and capacity information View source Unsuitable emergency department environment for psychiatric patients View source See 10 more concerns
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
Tracey Ostler · 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
Tracey Ostler, who had severe Emotionally Unstable Personality Disorder and a history of self-harm and overdoses, took an overdose and cut her wrists on 12 June 2023. After paramedics attended her home on 16 June following a further overdose, they left her there after deciding she had capacity to refuse hospital treatment; she was later found unconscious and died in hospital on 18 June 2023. The principal concerns were inadequate capacity assessment and clinical consultation, failures to share information and coordinate mental-health and ambulance care, the absence of multi-agency safety planning, and insufficient psychiatric hospital beds.
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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Unclear legal authority for preventing psychiatric patients leaving the emergency department
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Unavailability of appropriately trained mental health nurses for acute psychiatric patients
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them . This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients .
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Unclear ultimate clinical responsibility for psychiatric patients in the emergency department
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient .
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Compromised emergency department capacity to meet physically ill patients' needs
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate multidisciplinary psychiatric ward-based care
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team .
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Lack of psychiatric hospital beds resulting in prolonged emergency department detention
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds . The longest wait by such a patient in these circumstances has been 6 weeks . There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed .
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake thorough mental capacity assessments for life-threatening treatment decisions
Wider context from the report “Training for Paramedics to undertake Capacity Assessments.
Addressed to the Health and Care Professionals Council and South East Coast Ambulance Service
3. I found that the paramedics who attended Ms Ostler on the 16th June 2023, and assessed her capacity to refuse lifesaving treatment after taking a serious paracetamol overdose, failed to undertake a thorough capacity assessment . In particular, they failed to assess adequately whether she had the ability to weigh up the information being given to her .
4. Ms Ostler was recorded in written evidence provided by the more senior attending paramedic who attended as saying that she would not discuss why she wanted to die. A more senior paramedic, who reviewed that evidence for the purposes of the inquest, regarded the written evidence as demonstrating that the capacity assessment had been undertaken appropriately.
5. Neither the attending paramedic nor the reviewing paramedic appreciated that unless the patient was able to tell them why she had decided that she wanted to die, that she had not demonstrated to them how she had weighed up the information available to her. Therefore, a full capacity assessment could not be completed.
6. I am concerned that the training they had received, both whilst students and subsequently, had not been adequate to equip them to undertake adequate capacity assessments.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure to provide lawful Mental Health Act detention safeguards and Responsible Clinician oversight
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department . There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983 . In addition, they do not have a Responsible Clinician .
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Inadequate paramedic training for mental capacity assessments
Wider context from the report “Training for Paramedics to undertake Capacity Assessments.
Addressed to the Health and Care Professionals Council and South East Coast Ambulance Service
3. I found that the paramedics who attended Ms Ostler on the 16th June 2023, and assessed her capacity to refuse lifesaving treatment after taking a serious paracetamol overdose, failed to undertake a thorough capacity assessment. In particular, they failed to assess adequately whether she had the ability to weigh up the information being given to her.
4. Ms Ostler was recorded in written evidence provided by the more senior attending paramedic who attended as saying that she would not discuss why she wanted to die. A more senior paramedic, who reviewed that evidence for the purposes of the inquest, regarded the written evidence as demonstrating that the capacity assessment had been undertaken appropriately.
5. Neither the attending paramedic nor the reviewing paramedic appreciated that unless the patient was able to tell them why she had decided that she wanted to die, that she had not demonstrated to them how she had weighed up the information available to her. Therefore, a full capacity assessment could not be completed.
6. I am concerned that the training they had received, both whilst students and subsequently, had not been adequate to equip them to undertake adequate capacity assessments.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Inadequate and unavailable protocol for capacity assessments in life-threatening circumstances
Wider context from the report “South East Coast Ambulance Service’s protocol on undertaking capacity assessments in relation to life threatening decisions.
Addressed to the South East Coast Ambulance Service
7. The Trusts policy on Mental Capacity is being reviewed to improve articulation of how to assess mental capacity in life threatening circumstances. It is not yet available . I regarded the current policy as inadequate and remain concerned about this because I have not been able to review the revised document.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for joint ambulance and mental health emergency plans
Wider context from the report “Multi Agency Safeguarding Plans
Addressed to the Surrey and Borders Partnership Trust and South East Coast Ambulance Service
8. Ms Ostler suffered from a severe Emotionally Unstable Personality Disorder, this was a longstanding diagnosis, and the effects were well known to her mental health team. She was placed in the community on a Positive Risk Taking Plan. She presented a continuous and serious risk to herself in the community and was prone to impulsive acts of self harm. Ambulances were frequently required to attend her home after such acts. The disorder impacted her ability to make capacious decisions about her own care.
9. The independent expert consultant psychiatrist called at the inquest regarded it as good practice in these circumstances to have a joint plan in place, including liaison between the ambulance service and mental health teams, for dealing with emergencies .
10. No system currently exists in Surrey to create such plans.
11. The paramedics who attended Ms Ostler on the 16th June 2023 did not know she had a diagnosis of Emotionally Unstable Personality Disorder, nor that this such a diagnosis would be likely to affect her decision-making capacity because it made her more prone to be volatile and impulsive.
12. The psychiatric evidence was that she would be likely to lack capacity.
13. Paramedics assessing her lacked this vital information. In consequence, she was left at home to die.
14. I have not been provided with any Protocol between the services to ensure safety planning in these circumstances that would ensure that front line paramedics are made aware that they are dealing with a seriously unwell mental health patients who is at high risk living in the community.
15. I therefore remain concerned that such a death could occur again.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure to provide frontline paramedics with vital mental health risk and capacity information
Wider context from the report “Multi Agency Safeguarding Plans
Addressed to the Surrey and Borders Partnership Trust and South East Coast Ambulance Service
8. Ms Ostler suffered from a severe Emotionally Unstable Personality Disorder, this was a longstanding diagnosis, and the effects were well known to her mental health team. She was placed in the community on a Positive Risk Taking Plan. She presented a continuous and serious risk to herself in the community and was prone to impulsive acts of self harm. Ambulances were frequently required to attend her home after such acts. The disorder impacted her ability to make capacious decisions about her own care.
9. The independent expert consultant psychiatrist called at the inquest regarded it as good practice in these circumstances to have a joint plan in place, including liaison between the ambulance service and mental health teams, for dealing with emergencies.
10. No system currently exists in Surrey to create such plans.
11. The paramedics who attended Ms Ostler on the 16th June 2023 did not know she had a diagnosis of Emotionally Unstable Personality Disorder , nor that this such a diagnosis would be likely to affect her decision-making capacity because it made her more prone to be volatile and impulsive.
12. The psychiatric evidence was that she would be likely to lack capacity.
13. Paramedics assessing her lacked this vital information. In consequence, she was left at home to die.
14. I have not been provided with any Protocol between the services to ensure safety planning in these circumstances that would ensure that front line paramedics are made aware that they are dealing with a seriously unwell mental health patients who is at high risk living in the community.
15. I therefore remain concerned that such a death could occur again.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Unsuitable emergency department environment for psychiatric patients
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” Open source report
×
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 an investigation into ambulance responses to mental health crisis calls via NHS 111 and 999, covering triage, training, capacity assessment, and conveyance decisions.
Verbatim wording from the response “Mental Health Crisis: Ambulance service response via NHS 111 and 999” Source location Response from Health Service Safety Investigations Body
Open published response
×
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 an investigation into mental health crisis care for patients in emergency departments, covering resources, environments, and admission or discharge decisions.
Verbatim wording from the response “Mental Health Crisis: Care of patients in emergency departments” Source location Response from Health Service Safety Investigations Body
Open published response
Concerns raised 8 Gap in fitness-to-practise oversight for unregistered technicians View source Failure to assess and manage staff fitness to practise after identified deficiencies View source Failure of the ambulance service to implement collective learning from identified ECG training gaps View source Failure to correctly interpret 12 lead ECGs View source Failure to note or act upon auto-diagnostic ECG reports View source Failure to provide accurate information about observations and ECG findings View source Lack of qualitative assessment of ECG training View source Lack of further ECG training after identified incorrect interpretation View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lauren Page Smith · 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
Lauren Page Smith died at home on 6 January 2023 after paramedics attended to reported vomiting, chest pain and arm pain. An abnormal ECG, including an automated report of an anterior infarct, was interpreted as normal, and she declined hospital attendance after being given that incorrect information. The report raises concerns about ECG interpretation, training and assessment, and the absence of further action or safeguards addressing identified competency and patient-safety risks.
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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Gap in fitness-to-practise oversight for unregistered technicians
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████ . ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time . I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and manage staff fitness to practise after identified deficiencies
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles . I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure of the ambulance service to implement collective learning from identified ECG training gaps
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████ . There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician . Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly interpret 12 lead ECGs
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience .
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure to note or act upon auto-diagnostic ECG reports
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report .
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate information about observations and ECG findings
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct , and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Lack of qualitative assessment of ECG training
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training . I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time .
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Lack of further ECG training after identified incorrect interpretation
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg . I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” Open source report
×
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 Undertake exploratory work on the patient-safety issues raised about paramedic interpretation of ECGs in the community.
Verbatim wording from the response “On 20 December 2023, our Investigations and Insights team held an Intelligence Review Meeting; at this meeting we review all patient safety concerns and insights received into our organisation and consider them for further exploratory work. I would like to assure you that the Regulation 28 Report sent to us was considered in this meeting, along with other information available to us and I can confirm that further exploratory work is being undertaken in relation to the issues raised in your report.” Source location Response from Health Services Safety Investigations Body
Open published response
×
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 exploratory work by the end of January 2024 and consider the scope for an HSSIB investigation.
Verbatim wording from the response “This exploratory work will be further reviewed by the end of January 2024 when we will consider the scope for an HSSIB investigation into issues related to Paramedic interpretation of ECGs in the community.” Source location Response from Health Services Safety Investigations Body
Open published response
Concerns raised 5 Staff reluctance to accept confirmation bias and alter practices View source Failure to prioritise relevant staff for confirmation bias training View source Failure of all staff to consider and digest the Newsletters View source Failure of staff to understand confirmation bias View source Delayed completion of confirmation bias training by staff 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.
×
AI-generated summary
Clay Daniel Wanckiewicz · 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
Clay Daniel Wanckiewicz was born in very poor condition following failed forceps delivery and caesarean section complicated by a deeply impacted head, and died at 22 minutes of age from skull fractures. The principal concerns were confirmation bias, insufficiently open-minded assessment of the overall clinical picture, inadequate staff training and a continuing risk that similar situations could place mothers and babies at risk.
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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Staff reluctance to accept confirmation bias and alter practices
Wider context from the report “(1) Failure of members of staff to understand the concept of confirmation bias.
(2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices.
(3) I am not satisfied the Newsletters had been considered and digested by all staff.
(4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training.
These are the reasons for my belief that there continues to be a 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise relevant staff for confirmation bias training
Wider context from the report “(1) Failure of members of staff to understand the concept of confirmation bias.
(2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices.
(3) I am not satisfied the Newsletters had been considered and digested by all staff.
(4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training.
These are the reasons for my belief that there continues to be a 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure of all staff to consider and digest the Newsletters
Wider context from the report “(1) Failure of members of staff to understand the concept of confirmation bias.
(2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices.
(3) I am not satisfied the Newsletters had been considered and digested by all staff.
(4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training.
These are the reasons for my belief that there continues to be a 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to understand confirmation bias
Wider context from the report “(1) Failure of members of staff to understand the concept of confirmation bias.
(2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices.
(3) I am not satisfied the Newsletters had been considered and digested by all staff.
(4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training.
These are the reasons for my belief that there continues to be a 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Delayed completion of confirmation bias training by staff
Wider context from the report “(1) Failure of members of staff to understand the concept of confirmation bias.
(2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices.
(3) I am not satisfied the Newsletters had been considered and digested by all staff.
(4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training.
These are the reasons for my belief that there continues to be a risk.
” Open source report
Concerns raised 1 Failure to routinely swab orthopaedic surgery patients from care homes or with previous positive MRSA results on hospital admission View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joan Margaret Sanderson · 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 Margaret Sanderson died at Tameside General Hospital on 15 June 2020 after an accidental fall, surgery for a left hip fracture, and a subsequent MRSA infection. The principal concern was that an MRSA swab was not routinely collected on admission for orthopaedic patients from care homes or with a previous positive MRSA result, which could have enabled earlier identification of infection.
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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely swab orthopaedic surgery patients from care homes or with previous positive MRSA results on hospital admission
Wider context from the report “The inquest heard evidence from the Trust that following her death they had carried out a RCA to understand what learning could be taken from Mrs Sanderson’s death. A key piece of learning was identified, as patients being admitted for orthopaedic surgery, from a care home or those that have had a previous positive MRSA result should have a routine swab sent for MRSA on admission to hospital.
In this case a swab was not collected as that was not standard at that time. Surgery would not be held up awaiting the outcome but it would have allowed earlier identification of MRSA which could impact the outcome in another case where emergency surgery is required and there is an infection post operatively. Patients admitted for elective surgery have a MRSA swab collected 12 weeks prior and receive decolonisation treatment for a positive MRSA result prior to surgery.
The inquest was told this change had been rolled out in the trust and was seen as wider learning that could prevent future deaths within the NHS.
” Open source report
×
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 HSIB will not investigate because its limited annual investigation capacity requires selecting issues with the greatest potential for new NHS learning.
Verbatim wording from the response “Following careful consideration, we will not be taking forward an investigation into your concerns. We are only able to undertake a limited number of national investigations each year, and therefore try to focus on those with the most potential for new learning across the NHS. The National Criteria for selection is described on our website: https://www.hsib.org.uk/public-patients/how-we-decide-to-investigate/” Source location 2020-0198-Response-from-GM-Health-and-Social-Care-Partnership-and-Healthcare-Safety-Investigation-Branchwillbe.pdf
Open published response
Concerns raised 3 Lack of acute hospital bed capacity View source Failure to provide suitable waiting conditions in A and E View source Delays in putting care packages in place for medically optimised patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Joseph Michael Cheetham · 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
Joseph Michael Cheetham suffered an unwitnessed accidental fall, underwent surgery for a dislocated prosthetic hip, and later died in hospital on 22 January 2020 after pneumonia, dysphagia and respiratory deterioration. Concerns included prolonged waiting in the Emergency Department because of bed shortages and discharge home before a care package was in place, while he was frail and vulnerable and had lost weight in hospital.
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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Lack of acute hospital bed capacity
Wider context from the report “1. The inquest heard that his GP had sought to have him admitted directly into hospital having identified that he needed to be hospitalised. However, contact with the trust identified that the acute bed shortage meant that this would not be possible , and he would have to go via A and E. On arrival at A and E the volume of those waiting to be seen meant that he waited in cold and draughty areas of the department. Lack of bed capacity in the hospital meant that he spent over 24 hours in the A and E department despite being frail and vulnerable.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure to provide suitable waiting conditions in A and E
Wider context from the report “1. The inquest heard that his GP had sought to have him admitted directly into hospital having identified that he needed to be hospitalised. However, contact with the trust identified that the acute bed shortage meant that this would not be possible, and he would have to go via A and E. On arrival at A and E the volume of those waiting to be seen meant that he waited in cold and draughty areas of the department . Lack of bed capacity in the hospital meant that he spent over 24 hours in the A and E department despite being frail and vulnerable.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Delays in putting care packages in place for medically optimised patients
Wider context from the report “2. The inquest heard that he was medically optimised, and he had lost weight in hospital whilst awaiting a care package to be put in place . One was still not in place by 24th December and it was likely to be at least another 2-3 weeks before one was in place . To avoid further deconditioning and weight loss in an acute setting whilst awaiting a care package his family took on caring for him at home to facilitate a discharge.
” Open source report
Concerns raised 5 Insufficient detail in final investigation reports View source Factual errors and inaccuracies in initial investigation reports View source Delays in final investigation report completion View source Delays in HSIB investigation completion View source Restriction of Trust-led investigation during HSIB investigations View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Theo Benjamin Young · 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
Theo Benjamin Young was born by emergency caesarean section in a very poor condition after persistent abnormalities in fetal monitoring were not recognised during labour. He suffered non-survivable injuries from intrapartum hypoxia and died three days after delivery. Concerns included failures in staffing, fetal monitoring, escalation and oxytocin management, as well as delays and deficiencies in the subsequent HSIB investigation.
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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail in final investigation reports
Wider context from the report “3. The initial draft report contained factual errors and inaccuracies requiring considerable input by the Trust to resolve. The final report is insufficiently detailed and was completed 18 months after the death, during which time further deaths could have resulted.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Factual errors and inaccuracies in initial investigation reports
Wider context from the report “3. The initial draft report contained factual errors and inaccuracies requiring considerable input by the Trust to resolve. The final report is insufficiently detailed and was completed 18 months after the death, during which time further deaths could have resulted.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Delays in final investigation report completion
Wider context from the report “3. The initial draft report contained factual errors and inaccuracies requiring considerable input by the Trust to resolve. The final report is insufficiently detailed and was completed 18 months after the death , during which time further deaths could have resulted.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Delays in HSIB investigation completion
Wider context from the report “2. HSIB indicated to the Trust at the outset that their investigation would take approximately six months which is highly likely to delay the introduction of any immediate necessary measures by the Trust to prevent further deaths.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Restriction of Trust-led investigation during HSIB investigations
Wider context from the report “1. The HSIB specifically requested the Trust not to undertake their own investigation effectively preventing the recognition of causes of concern and therefore being unable to undertake any immediate and necessary remedial action at the earliest opportunity to prevent future deaths.
” Open source report
×
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 Escalate safety concerns identified during investigations to the relevant Head of Midwifery and Clinical Director.
Verbatim wording from the response “2. To further support trusts with rapidly addressing safety risks in their maternity services, HSIB investigators also immediately escalate any safety concerns uncovered during the investigation process to the Head of Midwifery and Clinical Director. This case was discussed at our clinical panel at the outset of the investigation, which identified key lines of enquiry, but the panel did not identify any preliminary findings which suggested an immediate risk to patient safety. Through our regular engagement processes, we ensure that prompt actions are taken by trusts in response to any matters raised through early escalation. Fortnightly written updates are sent to all Trust Heads of Midwifery to provide updates on the progress of HSIB’s local investigations and to seek support with addressing any barriers to progress.” Source location 2020-0094-Response-from-the-Healthcare-Safety-Investigation-Branch_Redacted
Open published response
×
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 Advise NHS trusts to complete 72-hour reports for maternity cases eligible for investigation.
Verbatim wording from the response “1. It is HSIB policy that all NHS trusts are advised to complete 72-hour reports for cases that are referred as eligible for investigation. The purpose of this is to ensure that trusts can readily identify immediate safety concerns and take necessary actions while they await the commencement and outcome of HSIB’s more in-depth reviews. Trusts are not mandated to share their 72-hour reports, but many share them with HSIB voluntarily.” Source location 2020-0094-Response-from-the-Healthcare-Safety-Investigation-Branch_Redacted
Open published response
×
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 Send fortnightly written investigation updates to Trust Heads of Midwifery and seek support to address progress barriers.
Verbatim wording from the response “2. To further support trusts with rapidly addressing safety risks in their maternity services, HSIB investigators also immediately escalate any safety concerns uncovered during the investigation process to the Head of Midwifery and Clinical Director. This case was discussed at our clinical panel at the outset of the investigation, which identified key lines of enquiry, but the panel did not identify any preliminary findings which suggested an immediate risk to patient safety. Through our regular engagement processes, we ensure that prompt actions are taken by trusts in response to any matters raised through early escalation. Fortnightly written updates are sent to all Trust Heads of Midwifery to provide updates on the progress of HSIB’s local investigations and to seek support with addressing any barriers to progress.” Source location 2020-0094-Response-from-the-Healthcare-Safety-Investigation-Branch_Redacted
Open published response
×
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 Regular communication and safety information during investigations were considered sufficient to allow trusts to introduce immediate preventive measures before reports were issued.
Verbatim wording from the response “This report did exceed our target timescale; however, HSIB communicated regularly with SaSH Trust and the family during the investigation process and provided the Trust with relevant safety information. This is a standard process in our investigations as detailed in the response above and enables trusts to introduce any immediately necessary measures to prevent future deaths before the sharing of our report.” Source location 2020-0094-Response-from-the-Healthcare-Safety-Investigation-Branch_Redacted
Open published response
×
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 72-hour reviews, safety escalations, trust engagement and thematic reviews were considered sufficient to support timely risk identification and action.
Verbatim wording from the response “HSIB places utmost importance on the need to ensure that rapid learning takes place for cases that fall within the eligibility criteria of HSIB’s maternity investigation programme. There are several stages throughout HSIB investigations where the opportunity for identifying and addressing safety risks is provided to trusts, and these were implemented during the investigation of baby Theo’s death.” Source location 2020-0094-Response-from-the-Healthcare-Safety-Investigation-Branch_Redacted
Open published response
×
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 final report was considered detailed and was shared 14 months after death, not 18 months; most alleged factual errors were rejected.
Verbatim wording from the response “HSIB consider that the report provides detailed reflection of the investigation that was undertaken. Evidence was collated from the medical records, Trust guidelines and policies and interviews with the family and staff (as outlined as requirements in paragraph 3 (3) of the HSIB Maternity Directions 2018).” Source location 2020-0094-Response-from-the-Healthcare-Safety-Investigation-Branch_Redacted
Open published response
Concerns raised 9 Delays in reviewing pathological CTG View source Shortage of midwives in the enhanced midwifery team View source Failure to make decisions in accordance with trust guidance View source Failure to recognise early signs of sepsis and clinical deterioration in the NICU View source Lack of clarity about supporting and managing vulnerable families View source Failure to clearly document clinical decision-making in the notes View source Shortage of experienced social workers in the Local Authority View source Lack of communication between midwifery and social work teams View source Failure to document triage calls and advice View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Caspian Thorn · 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
Caspian Thorn was born with significant brain damage after chronic placental insufficiency and died in hospital on 29 September 2018 after developing a gram-negative hospital-acquired infection and sepsis. The concerns included failure to offer induction or follow up a missed growth scan, poor communication and support for a vulnerable family, undocumented triage calls, inadequate documentation of decision-making, delayed recognition of a pathological CTG, and delayed recognition of signs of sepsis.
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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Delays in reviewing pathological CTG
Wider context from the report “5. The 1st CTG on 24th September was a pathological CTG from the very early stages but was not reviewed until half an hour had elapsed despite the history . An expectation that CTG should be observed for a period of time after first starting would have allowed for earlier identification of fetal distress ;
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Shortage of midwives in the enhanced midwifery team
Wider context from the report “1. A feature of the evidence was a lack of communication between the teams of midwives and social worker. This meant that it was not picked up that his mother had missed a key fetal growth scan and that a small baby was not monitored for the period between 10th September until his birth on 24th September. The inquest heard that contributing to this was a shortage of midwives in the enhanced midwifery team and a shortage of experienced social workers in the Local Authority at the time;
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure to make decisions in accordance with trust guidance
Wider context from the report “4. Decision making that was not in accordance with trust guidance on 10th September was not clearly documented in the notes;
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise early signs of sepsis and clinical deterioration in the NICU
Wider context from the report “6. Early signs of sepsis were not identified by the consultant neonatologist because it was thought the observations reflected a move to warming from cooling. The other experienced staff within the NICU did not appear to recognise a deteriorating position until 12 hours after early signs of deterioration were noted .
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about supporting and managing vulnerable families
Wider context from the report “2. Caspian’s family had been identified as vulnerable. There was a lack of clarity about how to effectively support and manage the situation to ensure that there was effective engagement throughout the pregnancy and during delivery;
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly document clinical decision-making in the notes
Wider context from the report “4. Decision making that was not in accordance with trust guidance on 10th September was not clearly documented in the notes ;
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Shortage of experienced social workers in the Local Authority
Wider context from the report “1. A feature of the evidence was a lack of communication between the teams of midwives and social worker. This meant that it was not picked up that his mother had missed a key fetal growth scan and that a small baby was not monitored for the period between 10th September until his birth on 24th September. The inquest heard that contributing to this was a shortage of midwives in the enhanced midwifery team and a shortage of experienced social workers in the Local Authority at the time;
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Lack of communication between midwifery and social work teams
Wider context from the report “1. A feature of the evidence was a lack of communication between the teams of midwives and social worker . This meant that it was not picked up that his mother had missed a key fetal growth scan and that a small baby was not monitored for the period between 10th September until his birth on 24th September. The inquest heard that contributing to this was a shortage of midwives in the enhanced midwifery team and a shortage of experienced social workers in the Local Authority at the time;
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure to document triage calls and advice
Wider context from the report “3. There had been two undocumented calls to triage on the morning of 24th September 2018. The inquest heard that when staff were busy on the triage team calls and advice were not always documented ;
” Open source report
Concerns raised 7 Failure to provide community health professionals with clear instructions for head-circumference monitoring and action View source Unavailability of paper clinical notes to clinicians at appointments View source Delays in sending post-outpatient clinical letters and requests for assessment View source Failure to maintain a complete composite child health record in the red book View source Lack of a defined protocol for transfer of paediatric care between tertiary centres and DGHs View source Failure of information systems to make key clinical information available across trusts View source Failure to provide timely and accurately directed discharge information identifying the responsible paediatrician View source See 4 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
Joseph James GRANTHAM · 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
Joseph James Grantham was born with a neural tube defect and later developed laryngomalacia. He became unresponsive at church on 9 July 2017, and resuscitation efforts were unsuccessful; the post-mortem found no cause of death and the death was attributed to natural causes. Concerns included delays and gaps in sharing clinical information, unclear responsibility for his care, unavailable records, and insufficient communication about monitoring requirements between healthcare 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure to provide community health professionals with clear instructions for head-circumference monitoring and action
Wider context from the report “4. Joseph had been diagnosed by the neurosurgeons at RMCH with neural tube defect (cervical meningocele, hydrocephalus, Arnold Chiari type II malformation. A recognised complication is hydrocephalus. Identification of the onset of hydrocephalus is through measurement of head circumference. The inquest heard that when Joseph was discharged from St Mary's the neurosurgical team did not send written instructions to community health professionals explaining what was required and why it was required. The midwives measuring his head were unsure why they were measuring it or what to do with the information.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Unavailability of paper clinical notes to clinicians at appointments
Wider context from the report “3. At ENT appointments and neurosurgery appointments at the RMCH, Joseph was seen without the paper notes because they had not been made available to the clinicians seeing Joseph.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Delays in sending post-outpatient clinical letters and requests for assessment
Wider context from the report “2. Joseph was under the care of the paediatric neurosurgical team at the Royal Manchester Children's Hospital (RMCH). Letters from the neurosurgical team following out-patient appointments took 4 weeks to be sent out. As a result one letter to a paediatric anaesthetist asking for an examination was not typed until after the operation was due to take place. When his mother took him for review, she had to escalate the need for him to be seen by the paediatric anaesthetist who then deemed him not fit at that time for surgery.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a complete composite child health record in the red book
Wider context from the report “6. Joseph's red book had been completed sporadically. The inquest heard from a number of witnesses who indicated that practice re completion of the red book amongst health professionals nationally was mixed and that there was no clear guidance for or expectation amongst health professionals that they would be widely used other than for post birth weight recording and immunisations. As a result there was no composite record of health concerns for a young child such as Joseph. Differing IT systems meant that health professionals in different trusts were reliant on verbal information passed to parents placing a significant burden on parents and a risk that key information was not available.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Lack of a defined protocol for transfer of paediatric care between tertiary centres and DGHs
Wider context from the report “5. Joseph's health needs relating to neural tube defect (cervical meningocele, hydrocephalus, Arnold Chiari type II malformation and laryngomalacia were dealt with by the RMCH. His paediatric care was transferred without discussion by St Mary's back to the DGH. The inquest was told that there is no set protocol/ procedure between tertiary centres and DGH's for this situation, which can lead to differing practices.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure of information systems to make key clinical information available across trusts
Wider context from the report “6. Joseph's red book had been completed sporadically. The inquest heard from a number of witnesses who indicated that practice re completion of the red book amongst health professionals nationally was mixed and that there was no clear guidance for or expectation amongst health professionals that they would be widely used other than for post birth weight recording and immunisations. As a result there was no composite record of health concerns for a young child such as Joseph. Differing IT systems meant that health professionals in different trusts were reliant on verbal information passed to parents placing a significant burden on parents and a risk that key information was not available.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely and accurately directed discharge information identifying the responsible paediatrician
Wider context from the report “1. After his birth Joseph was transferred to the neonatal unit at St Mary's due to the complexities of his health. Following his discharge, it took 6 weeks for the trust to send the discharge paperwork to the GP and the District General Hospital (DGH) to whom they were transferring his paediatric care. As a result, there was no clear understanding amongst health professionals as to the paediatrician with responsibility for his care . Letters were therefore copied into a mixture of paediatricians. The discharge letter to the DGH was addressed to a consultant who was in fact a registrar at the trust.
” Open source report
Concerns raised 2 Failure of multidisciplinary team members to challenge incorrect clinical decisions View source Lack of routine pre-delivery scanning for breech presentation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Aniyah Jasmine Winston · 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
Aniyah Jasmine Winston was delivered vaginally in an undetected breech presentation and was in poor condition at birth after manipulation during delivery. Resuscitation was commenced and ceased at 10:59am. The concerns included the challenges of undetected breech births and the administration of Syntocinon without further review, examination, counselling or a written prescription; professionals involved reportedly felt unable to challenge the decision.
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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure of multidisciplinary team members to challenge incorrect clinical decisions
Wider context from the report “2. The inquest was told by a number of medical professionals involved in Aniyah's birth that they whilst they felt the decision to give Syntocinon was incorrect they did not feel comfortable challenging the decision . The expert instructed was clear that at the time it was given it should not have been . The Trust has since the death of Aniyah put in place a detailed programme to improve confidence in challenging decision-making within a MDT setting. However the extent of recognition of the issue and steps to counter it nationally were unclear.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Lack of routine pre-delivery scanning for breech presentation
Wider context from the report “1. The inquest heard that Aniyah was an undetected breech birth. By the time it was identified she was breech her mother was fully dilated. The inquest heard that there are undetected breech births are not uncommon and present particular challenges for those involved in care during labour. The inquest was told that it is the case that pre delivery scans are not routinely carried out to try and reduce the number of undetected breeches and midwives/doctors rely on external examination. The inquest was told that this is due to availability of scanning facilities and training to utilise the scanners .
” Open source report
Concerns raised 4 Failure to seek guidance during rapidly evolving labour situations View source Lack of structured and direct information sharing between hospital and ambulance services View source Lack of paramedic experience in managing footling breech deliveries View source Failure to provide or seek continuing expert support during footling breech deliveries View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
George French Russell · 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
George French Russell was born prematurely at 35 weeks and 1 day following a footling breech birth on 11 January 2017, in poor condition and with severe brain damage. He died on 23 January 2017 after being transferred for neonatal care. Concerns included inadequate information-sharing between services and a lack of sustained expert input during the breech delivery.
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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure to seek guidance during rapidly evolving labour situations
Wider context from the report “1. During the inquest it became clear that during the telephone conversation between EMAS and George’s mother her labour was rapidly developing. There was no evidence of the call taker seeking guidance on how to deal with a rapidly evolving situation other than to update the ambulance crew who were on route. (EMAS)
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Lack of structured and direct information sharing between hospital and ambulance services
Wider context from the report “2. The way in which information was exchanged between Stepping Hill Hospital and EMAS meant that all those involved in making decisions were not in possession of key facts. There was no structure to how information was shared and it was passed 3rd hand .
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Lack of paramedic experience in managing footling breech deliveries
Wider context from the report “3. During labour EMAS were present. The paramedics did not have the experience to deal with a footling breech delivery . Expert input was given for a brief period by a registrar but when that conversation terminated there was no further support given or sought.
” 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 Health Services Safety Investigations Body; that does not assign responsibility.
PFD Monitor interpretation Failure to provide or seek continuing expert support during footling breech deliveries
Wider context from the report “3. During labour EMAS were present. The paramedics did not have the experience to deal with a footling breech delivery. Expert input was given for a brief period by a registrar but when that conversation terminated there was no further support given or sought .
” 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 HSIB cannot investigate this case because it occurred before the organisation became operational and falls outside its investigation criteria.
Verbatim wording from the response “As you may be aware, the HSIB was set up to investigate systemic safety issues that cut across organisational boundaries. We conduct up to 30 investigations a year and focus on those with the most potential for new learning that have taken place after we became operational on 1st April, 2017. This case occurred before 1st April 2017 and therefore does not meet our criteria for investigation.” Source location 2018-0062-Response-by-HSIB
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Addressed to Healthcare Safety Investigation Branch, now represented here by Health Services Safety Investigations Body.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations