16 Jun 2016 Valerie Margaret Ellis · Prevention of Future Deaths report West Sussex
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Concerns raised 7 Lack of a policy for discharge counselling and warning cards for Apixaban View source Failure to consult clinical advisors in complex KMSS 111 cases View source Inadequate training of KMSS 111 health advisors to recognise potentially fatal illnesses and deteriorating conditions View source Imprecision and unresolved improvement of the NHS Pathways clinical algorithm View source Failure of IC24 case management to keep telephone referrals open until planned callbacks occur View source Poorly organised training for IC24 clinical staff in use of the computer system View source Failure to arrange a joint RCA of KMSS 111 and IC24 investigations View source See 4 more concerns
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Valerie Margaret Ellis · 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
Valerie Margaret Ellis, an 83-year-old woman, died at home on 6 September 2015 after a massive gastrointestinal bleed associated with Apixaban. The report identified concerns about inadequate counselling on the medication, communication and call-handling problems in NHS 111, premature closure of an IC24 case, and aspects of ambulance triage.
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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 Integrated Care 24; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy for discharge counselling and warning cards for Apixaban
Wider context from the report “1) On discharge from the hospital the use of Apixaban in an elderly confused patient being cared for by a carer with hearing loss should have merited careful counselling by the clinicians and the use of a warning card.
Whilst the hospital is taking steps to assess this area, my understanding is that no policy has been adopted and I feel it should be made a matter of urgency.
” 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 Integrated Care 24; that does not assign responsibility.
PFD Monitor interpretation Failure to consult clinical advisors in complex KMSS 111 cases
Wider context from the report “2) KMSS 111 provides a valuable lifeline for many patients and although health advisors are trained to follow algorithms they only have 4 weeks training followed by 2 weeks of sitting in with an experienced advisor. I am concerned about the training schedule, particularly for those with little or no background medical knowledge. Whilst reliant on algorithms, advisors must be able to recognise potentially fatal illnesses and deteriorating conditions as thousands of patients rely on this service for medical help. Clinical advisors on duty were not consulted in this complex case. The senior manager for Quality and Clinical Governance at KMSS 111 expressed concern at the algorithm used in the case of Mrs Ellis. The clinical algorithm called NHS Pathways is owned by the Department of Health and was felt to be imprecise but despite representations to the Department of Health by KMSS 111 for changes and improvement there has been no positive communication since February.
” 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 Integrated Care 24; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of KMSS 111 health advisors to recognise potentially fatal illnesses and deteriorating conditions
Wider context from the report “2) KMSS 111 provides a valuable lifeline for many patients and although health advisors are trained to follow algorithms they only have 4 weeks training followed by 2 weeks of sitting in with an experienced advisor . I am concerned about the training schedule, particularly for those with little or no background medical knowledge . Whilst reliant on algorithms, advisors must be able to recognise potentially fatal illnesses and deteriorating conditions as thousands of patients rely on this service for medical help. Clinical advisors on duty were not consulted in this complex case. The senior manager for Quality and Clinical Governance at KMSS 111 expressed concern at the algorithm used in the case of Mrs Ellis. The clinical algorithm called NHS Pathways is owned by the Department of Health and was felt to be imprecise but despite representations to the Department of Health by KMSS 111 for changes and improvement there has been no positive communication since February.
” 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 Integrated Care 24; that does not assign responsibility.
PFD Monitor interpretation Imprecision and unresolved improvement of the NHS Pathways clinical algorithm
Wider context from the report “2) KMSS 111 provides a valuable lifeline for many patients and although health advisors are trained to follow algorithms they only have 4 weeks training followed by 2 weeks of sitting in with an experienced advisor. I am concerned about the training schedule, particularly for those with little or no background medical knowledge. Whilst reliant on algorithms, advisors must be able to recognise potentially fatal illnesses and deteriorating conditions as thousands of patients rely on this service for medical help. Clinical advisors on duty were not consulted in this complex case. The senior manager for Quality and Clinical Governance at KMSS 111 expressed concern at the algorithm used in the case of Mrs Ellis. The clinical algorithm called NHS Pathways is owned by the Department of Health and was felt to be imprecise but despite representations to the Department of Health by KMSS 111 for changes and improvement there has been no positive communication since February .
” 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 Integrated Care 24; that does not assign responsibility.
PFD Monitor interpretation Failure of IC24 case management to keep telephone referrals open until planned callbacks occur
Wider context from the report “3) A disposition from 111 was made to IC24 for a telephone consultation by an on call clinician. This was received and logged and a call was made within one hour. There was no response by the carer and a note was made to call back within 5 minutes. Apparently the case was closed before this could occur ; no explanation could be given as to why this happened . Training for clinical staff in the use of the computer system used by IC24 is essential but did not appear well organised and should be rectified.
” 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 Integrated Care 24; that does not assign responsibility.
PFD Monitor interpretation Poorly organised training for IC24 clinical staff in use of the computer system
Wider context from the report “3) A disposition from 111 was made to IC24 for a telephone consultation by an on call clinician. This was received and logged and a call was made within one hour. There was no response by the carer and a note was made to call back within 5 minutes. Apparently the case was closed before this could occur; no explanation could be given as to why this happened. Training for clinical staff in the use of the computer system used by IC24 is essential but did not appear well organised and should be rectified.
” 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 Integrated Care 24; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange a joint RCA of KMSS 111 and IC24 investigations
Wider context from the report “4) The results of investigations by both KMSS 111 and IC24 should result in a joint RCA. This has not occurred as yet and no date has apparently been arranged .
” 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 Implement Failed Contact Guidance and software preventing call closure until three contact attempts are completed.
Verbatim wording from the response “As explained in evidence at the inquest in evidence by ████████ since this case IC24 have introduced a new Failed Contact Guidance and a new software version which means that it is not possible to close a call before three attempts spread over the timeframes set out in the Guidance have been made. This change has improved the process and the software. All new users of the software are trained in this regard, and all established users have been informed of and reminded about the correct process.” Source location 2016-0252-Response-by-Integrated-Care-24-Limited
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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 Conduct a joint IC24–KMSS meeting to discuss cross-organisational learning and review the case.
Verbatim wording from the response “A Joint meeting took place between IC24 and KMSS NHS 111 on 31 December 2015. At this meeting learning across the organisations was discussed and in particular Mrs Ellis case was reviewed. The note of that meeting is attached to this letter for your ease of reference.” Source location 2016-0252-Response-by-Integrated-Care-24-Limited
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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 Train new software users and remind established users of the required call-closure process.
Verbatim wording from the response “As explained in evidence at the inquest in evidence by ████████ since this case IC24 have introduced a new Failed Contact Guidance and a new software version which means that it is not possible to close a call before three attempts spread over the timeframes set out in the Guidance have been made. This change has improved the process and the software. All new users of the software are trained in this regard, and all established users have been informed of and reminded about the correct process.” Source location 2016-0252-Response-by-Integrated-Care-24-Limited
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A further joint RCA is considered unnecessary because joint learning has occurred and existing/new processes and actions are expected to yield no new learning.
Verbatim wording from the response “A Joint meeting took place between IC24 and KMSS NHS 111 on 31 December 2015. At this meeting learning across the organisations was discussed and in particular Mrs Ellis case was reviewed. The note of that meeting is attached to this letter for your ease of reference.” Source location 2016-0252-Response-by-Integrated-Care-24-Limited
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations