Concerns raised 2 Insufficient understanding of Category 1 response criteria for hanging incidents View source Failure to telephone the person when relevant information is incomplete View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lucy Ann THORNTON · 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
Lucy Ann THORNTON died on 18 February 2025 after suspending herself; the time of death and whether there was a missed opportunity to prevent this could not be ascertained. The report raises concerns about call handlers’ training and understanding of procedures for incidents involving hanging, including response categorisation and failure to telephone THORNTON for further information.
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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of Category 1 response criteria for hanging incidents
Wider context from the report “The level of training and understanding of relevant call handling procedures and processes by those employed as call handlers in relation to incidents concerning hanging:
1 The procedures direct a Category 1 response (7 minutes) when the person has the means to suspend themselves and has stated that is there present intention.
The call handler believes that a Category 1 response is, "When they are going to die now".
2 The procedures direct that when the call handler does not have all relevant information they should telephone the person and ask questions in relation to the person's present situation.
The call handler was on the Isle of Wight. THORNTON was in Southsea. The call handler did not call THORNTON as she felt she was too remote (geographically).
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to telephone the person when relevant information is incomplete
Wider context from the report “The level of training and understanding of relevant call handling procedures and processes by those employed as call handlers in relation to incidents concerning hanging:
1 The procedures direct a Category 1 response (7 minutes) when the person has the means to suspend themselves and has stated that is there present intention.
The call handler believes that a Category 1 response is, "When they are going to die now".
2 The procedures direct that when the call handler does not have all relevant information they should telephone the person and ask questions in relation to the person's present situation.
The call handler was on the Isle of Wight. THORNTON was in Southsea. The call handler did not call THORNTON as she felt she was too remote (geographically).
” 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 Deliver mandatory refresher training and updated materials on suicidal-patient call management, escalation, response categories, information gathering, and risk assessment.
Verbatim wording from the response “Additional training has been introduced for all call handlers to reinforce the appropriate management of calls involving suicidal patients.” Source location Response from Isle of Wight NHS Trust
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 Continue working with national bodies to strengthen guidance and NHS Pathways for risks involving suicidal patients and potential hanging.
Verbatim wording from the response “The Trust remains fully committed to learning from this incident and to strengthening its systems and processes to reduce the risk of similar occurrences in the future. We will continue to work with national bodies to ensure that guidance and NHS Pathways appropriately reflect the risks associated with suicidal patients, including those involving potential hanging.” Source location Response from Isle of Wight NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request national review of whether Category 1 disposition is appropriate for patients threatening to hang themselves.
Verbatim wording from the response “This incident and your Prevention of Future Deaths report will be formally reported to the national NHS Pathways group. It has also been raised at the National Heads of Emergency Operations Centre meeting, with a request that existing pathways be reviewed to consider whether a Category 1 disposition is appropriate in such circumstances.” Source location Response from Isle of Wight NHS Trust
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 Amend guidance to require reasonable direct contact attempts with individuals at risk wherever they are located when information is incomplete.
Verbatim wording from the response “Guidance has been amended and strengthened to make clear that where relevant information is incomplete, call handlers must make reasonable attempts to contact the individual directly, wherever they are located, in order to obtain information necessary for an accurate risk assessment.” Source location Response from Isle of Wight NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National NHS Pathways bodies are responsible for deciding whether Category 1 responses are appropriate for potential hanging incidents.
Verbatim wording from the response “At present, there is no NHS Pathways outcome that results in a Category 1 response for a patient threatening to hang themselves, even where means are present. A Category 1 response is only triggered where a patient is actively in the process of hanging.” Source location Response from Isle of Wight NHS Trust
Open published response
28 Mar 2019 Wayne Andrew ROGERS · Prevention of Future Deaths report Isle of Wight
View report summary
Concerns raised 5 Failure to monitor and record safety channels for incident response View source Failure to coordinate manpower for incident response View source Insufficient ambulance capacity for emergency incidents during major events View source Inadequate criteria for abandoning racing during a major incident View source Omission of readily accessible safety knives from mandatory safety equipment requirements 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
Wayne Andrew ROGERS · 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
Wayne Andrew ROGERS, aged 62, died after being thrown from a racing yacht and dragged through the water when a spinnaker sheet became caught around his ankle during Cowes Week. He was rescued, received CPR, and was pronounced dead at hospital; the medical cause of death was drowning. The report raised concerns about ambulance capacity and emergency response arrangements, safety equipment, race abandonment criteria, and the use of continuous sheets on boats.
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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor and record safety channels for incident response
Wider context from the report “4) A review needs to be carried out of the Crisis Management Plan, with an emphasis on monitoring and recording of safety channels and manpower coordination for incident response.
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate manpower for incident response
Wider context from the report “4) A review needs to be carried out of the Crisis Management Plan, with an emphasis on monitoring and recording of safety channels and manpower coordination for incident response .
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient ambulance capacity for emergency incidents during major events
Wider context from the report “1) I was informed that during the course of Cowes Week Sailing Festival that there are approximately 7,000 competitors who travel to Cowes on the Isle of Wight to participate in the various events. In this instance, it was fortunate that an ambulance was available to convey the casualty to the hospital as an emergency. However, there are a finite number of ambulances on the Isle of Wight, and they are often overstretched to carry out routine work , without the possibility of an incident happening during this Sailing Festival.
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate criteria for abandoning racing during a major incident
Wider context from the report “6) A review needs to be carried out of the criteria for abandoning racing in the event of a major incident .
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Omission of readily accessible safety knives from mandatory safety equipment requirements
Wider context from the report “5) A review needs to be carried out of the published list of mandatory safety equipment, including mention of readily accessible safety knives .
” Open source report
18 Dec 2018 Natalie Zara HUNTER · Prevention of Future Deaths report Isle of Wight
View report summary
Concerns raised 2 Insufficient out-of-hours mental health/Crisis staffing View source Failure to provide timely Discharge Summaries to GPs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Natalie Zara HUNTER · 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
Natalie Zara HUNTER, who had a history of mental health and alcohol-related problems and 18 previous serious suicide attempts, was found deceased in her apartment on 16 March 2018 after suspending herself by a ligature. The report raised concerns about delayed or missing discharge summaries from the Isle of Wight NHS Trust, affecting continuity of GP and mental health care, and about insufficient out-of-hours mental health and crisis staffing on the Isle of Wight.
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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient out-of-hours mental health/Crisis staffing
Wider context from the report “5. During the course of the live evidence I heard from ████████, Service Manager for Community Mental Health Services at the Isle of Wight NHS Trust, in connection with the lack of sufficient numbers of out-of-hours mental health or Crisis staff which are available across the Isle of Wight . His evidence (which has since been supplemented by up-to-date figures), was that the team currently comprises of 11.1 full-time equivalent Band 6 mental health staff members, but it really requires 15.74 full-time equivalent appropriately qualified staff members which would necessitate 4.64 full-time equivalent additional staff to be funded and recruited in order to be able to offer a full and effective service.
6. The evidence was that there are currently insufficient funds in order for a full complement of out-of-hours mental health/Crisis staff to be deployed which is affecting the way in which the Mental Health service operates and delivers care to those who need it out-of-hours.
7. Accordingly, I have concerns that those who are vulnerable with mental health issues and who need to be seen out-of-hours are currently not in receipt of an adequately staffed out-of-hours mental health provision .
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely Discharge Summaries to GPs
Wider context from the report “1. Natalie HUNTER’s GP, ████████ gave live evidence about Miss HUNTER’s 18 previous serious attempts to take her life. During the course of his evidence he referred to the lack of Discharge Summaries from the Isle of Wight NHS Trust . He said it is not uncommon for a Discharge Summary not to be sent to a GP’s practice by the IOW NHS Trust, or if it is sent, for it to be sent very late after the patient has been discharged from the Trust .
2. ████████ raised concerns about this as the Discharge Summary should contain details of why the patient was admitted; what care they received during their time at the IOW NHS Trust; what medication they were prescribed, and whether such medication was intended to be continued; and whether there were going to require ongoing care/treatment as a result of this admission/treatment.
3. If no Discharge Summary is received , it has a big impact on the care that GPs are able to offer to their patients and the continuity of care which is needed, particularly in relation to mental health input.
4. On several occasions, ████████ had been unaware of the nature of the admissions (which were almost all linked to her serious suicidal attempts) – and significantly the ongoing risk of further attempts on Miss HUNTER’s life as he had either not received a Discharge Summary or had received it too late for it to have any meaningful input into Miss HUNTER’s care .
” 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 Establish a Medical Director-led workstream to improve the quality and timeliness of discharge summaries.
Verbatim wording from the response “The Trust fully accepts that there have been issues with discharge summaries across the organisation, and confirms that a work stream lead by the Medical Director is in place to improve the quality and timeliness of the discharge summary.” Source location 2018-0392-Isle-of-Wight-NHS-Trust
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 Conduct an in-depth review of discharge summaries and communications to GPs following relevant mental health contacts.
Verbatim wording from the response “The action plan sets out the expectation that Mental Health Services will conduct an in depth review of the current situation and include the quality of other communication that is sent to GPs to inform them of patients contact with the services.” Source location 2018-0392-Isle-of-Wight-NHS-Trust
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 Prepare and secure approval for a business case developed with the CCG and local authority for a revised out-of-hours care model.
Verbatim wording from the response “• A Business case has been prepared in collaboration with the CCG and local authority, and has been signed off by the Mental Health Divisional Board and Quality Committee. This will change the model of care for the single point of access, the community mental health team and result in the creation of a new wellbeing service. The aim of the new model is to improve access, responsiveness and quality of 24/7 service provision.” Source location 2018-0392-Isle-of-Wight-NHS-Trust
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 Map communication processes with staff groups and develop a standard operating procedure or flowchart.
Verbatim wording from the response “• The backdrop – process mapping with all staff groups and from this a Standard Operating Procedure (SOP)/flowchart will be developed.” Source location 2018-0392-Isle-of-Wight-NHS-Trust
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 Evaluate the most effective approach to providing safe 24-hour cover.
Verbatim wording from the response “• The service is constantly evaluating the most effective way to provide safe 24hr cover.” Source location 2018-0392-Isle-of-Wight-NHS-Trust
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 Present discharge-summary audit outcomes at Trust quality forums to share learning.
Verbatim wording from the response “• The outcome of the audit will be presented at quality forums across the Trust to share the learning from this evidence” Source location 2018-0392-Isle-of-Wight-NHS-Trust
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 Audit discharge-summary quality, including admission reasons, care received, and medication reviews or changes.
Verbatim wording from the response “• An audit into quality of discharge summaries to ensure they contain the reason for admission, care and treatment received during the episode of care and detail of any medication review or changes.” Source location 2018-0392-Isle-of-Wight-NHS-Trust
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 Use formal teaching sessions with junior doctors to embed learning from the discharge-summary audit.
Verbatim wording from the response “• The audit will be led by a Consultant Psychiatrist and will engage Junior Doctors at formal teaching sessions to ensure that learning outcomes are embedded.” Source location 2018-0392-Isle-of-Wight-NHS-Trust
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 Fill staffing vacancies with bank and agency cover to provide a 24-hour site-based service.
Verbatim wording from the response “• All staffing vacancies have been filled with bank and agency cover to ensure there is a 24 hour site based service (not deployable).” Source location 2018-0392-Isle-of-Wight-NHS-Trust
Open published response
1 Aug 2018 Cuthbert Anthony Stanley Hingert · Prevention of Future Deaths report Isle of Wight
View report summary
Concerns raised 7 Lack of training for clinicians in use of the JAC medicines database View source Failure to make immediate DATIX incident reports in accordance with hospital protocol View source Failure to check the medicines database before prescribing duplicate medication doses View source Failure to prevent inappropriate continuing prescriptions of Fondaparinux and Ticagrelor View source Failure to prescribe aspirin at the standard continuing dose View source Failure to ensure safe clinical decision-making when prescribing hypnotics to confused patients View source Delays in documenting verbal prescribing orders 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.
×
AI-generated summary
Cuthbert Anthony Stanley Hingert · 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
Cuthbert Anthony Stanley Hingert was admitted to hospital with shortness of breath and possible acute coronary syndrome, during which duplicate doses of antiplatelet and anticoagulant medications were given. He later became confused, fell and sustained a subdural haematoma, skull fracture and subarachnoid haemorrhage, dying in hospital on 5 March 2017. Concerns included failures to check the medicines database, inappropriate or potentially inappropriate prescribing, delayed documentation, inadequate staff training and failure to report a medication incident according to protocol.
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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training for clinicians in use of the JAC medicines database
Wider context from the report “4. There was evidence that at least one of the clinicians treating Mr Hingert had not been trained to use the JAC medicines database .
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make immediate DATIX incident reports in accordance with hospital protocol
Wider context from the report “7. Upon discovering the errors with the medications which are documented above, a nurse did not follow hospital protocol and make a DATIX incident report despite acknowledging that she should have done so immediately .
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check the medicines database before prescribing duplicate medication doses
Wider context from the report “1. The evidence revealed that the Medical Registrar did not check the JAC medicines database to see that Mr Hingert had already been administered a stat dose of antiplatelets and anticoagulant medication before prescribing second dose of these medications .
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent inappropriate continuing prescriptions of Fondaparinux and Ticagrelor
Wider context from the report “3. Mr Hingert had already been prescribed continuing doses of Fondaparinux and Ticagrelor , which (fortuitously) were not administered.
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prescribe aspirin at the standard continuing dose
Wider context from the report “2. The Medical Registrar prescribed aspirin to continue at 300mg rather than at the standard dose of 75mg daily .
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure safe clinical decision-making when prescribing hypnotics to confused patients
Wider context from the report “6. A decision was made to treat Mr Hingert, who was already confused, with the hypnotic Zopiclone , which may not have been a sound clinical decision .
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in documenting verbal prescribing orders
Wider context from the report “5. There was a 2-hour delay in writing up a verbal order with regard to a prescribing decision.
” Open source report
12 Dec 2017 Joseph Peter Dunne · Prevention of Future Deaths report Isle of Wight
View report summary
Concerns raised 2 Failure to prevent incorrectly authenticated or attributed access to and alteration of patient medical records View source Failure to make medical-record edits visible to treating clinicians 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 Peter Dunne · 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 Peter Dunne, aged 58, was discharged from hospital on 14 July 2015 after presenting with pain and feeling unwell, and was later found collapsed at home on 16 July 2015. He became unresponsive while using the toilet and was pronounced dead at 3.20 p.m.; the medical cause of death was peritonitis due to a perforated duodenal ulcer. The report raises concerns about Information Governance breaches that allowed clinical records, including an abnormal D-dimer result, to be deleted or altered and not seen by treating clinicians.
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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent incorrectly authenticated or attributed access to and alteration of patient medical records
Wider context from the report “1. I am concerned that there are clear breaches in Information Governance protocols . It is clear that there are IG issues which allow one Clinician to make entries or delete information from a patient’s medical records, when they are not correctly logged in to the database , or are doing so under a colleague’s log-in (which remains live after they've walked away from the computer terminal) . Matters are compounded inasmuch as these edits are then found to be invisible to those clinicians who are actually treating the patient, and are only ascertainable when an IT audit trail is undertaken. It should not be possible for Doctor A to be able to access records made by Doctor B and to alter those medical records .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make medical-record edits visible to treating clinicians
Wider context from the report “1. I am concerned that there are clear breaches in Information Governance protocols. It is clear that there are IG issues which allow one Clinician to make entries or delete information from a patient’s medical records, when they are not correctly logged in to the database, or are doing so under a colleague’s log-in (which remains live after they've walked away from the computer terminal). Matters are compounded inasmuch as these edits are then found to be invisible to those clinicians who are actually treating the patient , and are only ascertainable when an IT audit trail is undertaken . It should not be possible for Doctor A to be able to access records made by Doctor B and to alter those medical records.
” Open source report
Concerns raised 11 Lack of nursing staff empowerment and leadership View source Failure to provide continuous junior doctor or registrar cover for NICU View source Inadequate transfer policy and escalation indicators for tertiary assistance View source Lack of clarity about ANNP and SANNP roles and capacity View source Poor SANNP and ANNP training in recognition of respiratory distress and PPHN View source Failure to record and make NICU observations seamlessly viewable View source Lack of guidance on NBM decisions for children in respiratory distress View source Failure to ensure trainers are themselves trained in PPHN and respiratory distress View source Lack of a defined medical and nursing handover system and required information View source Lack of clear care plans and escalation markers View source Inadequate out-of-hours NICU staffing levels View source See 8 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
Owen Richard Widlake · 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
Owen Widlake was born full term and healthy but aspirated meconium and developed worsening respiratory failure. He died at Southampton General Hospital on 31 May 2016 after late diagnosis of persistent pulmonary hypertension of the newborn and an acute intraventricular haemorrhage. Concerns included staffing and medical cover, recognition and escalation of respiratory distress, observation records, staff training, transfer arrangements, and handovers.
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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of nursing staff empowerment and leadership
Wider context from the report “(1a) Staffing levels over the weekend and bank holiday, in particular the use of ANNP and SANNP trained staff to replace junior and registrar level doctors on duty covering NICU.
(1b) The need for a dedicated junior level doctor or registrar to be on duty 24 hours covering NICU, and not a limited 3 / 4 hour shift.
(1c) The need to clarify as to the role an ANNP or SANNP has, whether in a nursing capacity or medical capacity, and how they are perceived by other staff.
2) The observations for children in transition or admitted to NICU are not recorded seamlessly nor are easily viewable whether on a chart or graph.
3) The nursing staff do not appear able to escalate concerns either
i) due to lack of clear care plans and escalation markers
ii) poor training particularly the SANNP and ANNP in the recognition of respiratory distress and PPHN
ii) a lack of empowerment indicating a lack of leadership .
4) The on going training undertaken of nursing staff in relation to PPHN and respiratory distress has been the responsibility of SANNP ████████ and a consultant, with no indication that they have undertaken training themselves.
5) Concern as to staff deciding whether a child in respiratory distress should be NBM or not and what is the guidance on this.
6) The Transfer policy for this Trust and what would be guidance or indicators as to the seeking of tertiary level assistance and transfer, especially when a crisis point may be reached past 10pm.
7) What is the current system in place for handovers between medical staff and nursing staff, whether written or verbal, and what information must be included as part of that handover.
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide continuous junior doctor or registrar cover for NICU
Wider context from the report “(1a) Staffing levels over the weekend and bank holiday, in particular the use of ANNP and SANNP trained staff to replace junior and registrar level doctors on duty covering NICU.
(1b) The need for a dedicated junior level doctor or registrar to be on duty 24 hours covering NICU, and not a limited 3 / 4 hour shift .
(1c) The need to clarify as to the role an ANNP or SANNP has, whether in a nursing capacity or medical capacity, and how they are perceived by other staff.
2) The observations for children in transition or admitted to NICU are not recorded seamlessly nor are easily viewable whether on a chart or graph.
3) The nursing staff do not appear able to escalate concerns either
i) due to lack of clear care plans and escalation markers
ii) poor training particularly the SANNP and ANNP in the recognition of respiratory distress and PPHN
ii) a lack of empowerment indicating a lack of leadership.
4) The on going training undertaken of nursing staff in relation to PPHN and respiratory distress has been the responsibility of SANNP ████████ and a consultant, with no indication that they have undertaken training themselves.
5) Concern as to staff deciding whether a child in respiratory distress should be NBM or not and what is the guidance on this.
6) The Transfer policy for this Trust and what would be guidance or indicators as to the seeking of tertiary level assistance and transfer, especially when a crisis point may be reached past 10pm.
7) What is the current system in place for handovers between medical staff and nursing staff, whether written or verbal, and what information must be included as part of that handover.
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate transfer policy and escalation indicators for tertiary assistance
Wider context from the report “(1a) Staffing levels over the weekend and bank holiday, in particular the use of ANNP and SANNP trained staff to replace junior and registrar level doctors on duty covering NICU.
(1b) The need for a dedicated junior level doctor or registrar to be on duty 24 hours covering NICU, and not a limited 3 / 4 hour shift.
(1c) The need to clarify as to the role an ANNP or SANNP has, whether in a nursing capacity or medical capacity, and how they are perceived by other staff.
2) The observations for children in transition or admitted to NICU are not recorded seamlessly nor are easily viewable whether on a chart or graph.
3) The nursing staff do not appear able to escalate concerns either
i) due to lack of clear care plans and escalation markers
ii) poor training particularly the SANNP and ANNP in the recognition of respiratory distress and PPHN
ii) a lack of empowerment indicating a lack of leadership.
4) The on going training undertaken of nursing staff in relation to PPHN and respiratory distress has been the responsibility of SANNP ████████ and a consultant, with no indication that they have undertaken training themselves.
5) Concern as to staff deciding whether a child in respiratory distress should be NBM or not and what is the guidance on this.
6) The Transfer policy for this Trust and what would be guidance or indicators as to the seeking of tertiary level assistance and transfer , especially when a crisis point may be reached past 10pm .
7) What is the current system in place for handovers between medical staff and nursing staff, whether written or verbal, and what information must be included as part of that handover.
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about ANNP and SANNP roles and capacity
Wider context from the report “(1a) Staffing levels over the weekend and bank holiday, in particular the use of ANNP and SANNP trained staff to replace junior and registrar level doctors on duty covering NICU.
(1b) The need for a dedicated junior level doctor or registrar to be on duty 24 hours covering NICU, and not a limited 3 / 4 hour shift.
(1c) The need to clarify as to the role an ANNP or SANNP has, whether in a nursing capacity or medical capacity, and how they are perceived by other staff .
2) The observations for children in transition or admitted to NICU are not recorded seamlessly nor are easily viewable whether on a chart or graph.
3) The nursing staff do not appear able to escalate concerns either
i) due to lack of clear care plans and escalation markers
ii) poor training particularly the SANNP and ANNP in the recognition of respiratory distress and PPHN
ii) a lack of empowerment indicating a lack of leadership.
4) The on going training undertaken of nursing staff in relation to PPHN and respiratory distress has been the responsibility of SANNP ████████ and a consultant, with no indication that they have undertaken training themselves.
5) Concern as to staff deciding whether a child in respiratory distress should be NBM or not and what is the guidance on this.
6) The Transfer policy for this Trust and what would be guidance or indicators as to the seeking of tertiary level assistance and transfer, especially when a crisis point may be reached past 10pm.
7) What is the current system in place for handovers between medical staff and nursing staff, whether written or verbal, and what information must be included as part of that handover.
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor SANNP and ANNP training in recognition of respiratory distress and PPHN
Wider context from the report “(1a) Staffing levels over the weekend and bank holiday, in particular the use of ANNP and SANNP trained staff to replace junior and registrar level doctors on duty covering NICU.
(1b) The need for a dedicated junior level doctor or registrar to be on duty 24 hours covering NICU, and not a limited 3 / 4 hour shift.
(1c) The need to clarify as to the role an ANNP or SANNP has, whether in a nursing capacity or medical capacity, and how they are perceived by other staff.
2) The observations for children in transition or admitted to NICU are not recorded seamlessly nor are easily viewable whether on a chart or graph.
3) The nursing staff do not appear able to escalate concerns either
i) due to lack of clear care plans and escalation markers
ii) poor training particularly the SANNP and ANNP in the recognition of respiratory distress and PPHN
ii) a lack of empowerment indicating a lack of leadership.
4) The on going training undertaken of nursing staff in relation to PPHN and respiratory distress has been the responsibility of SANNP ████████ and a consultant, with no indication that they have undertaken training themselves.
5) Concern as to staff deciding whether a child in respiratory distress should be NBM or not and what is the guidance on this.
6) The Transfer policy for this Trust and what would be guidance or indicators as to the seeking of tertiary level assistance and transfer, especially when a crisis point may be reached past 10pm.
7) What is the current system in place for handovers between medical staff and nursing staff, whether written or verbal, and what information must be included as part of that handover.
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record and make NICU observations seamlessly viewable
Wider context from the report “(1a) Staffing levels over the weekend and bank holiday, in particular the use of ANNP and SANNP trained staff to replace junior and registrar level doctors on duty covering NICU.
(1b) The need for a dedicated junior level doctor or registrar to be on duty 24 hours covering NICU, and not a limited 3 / 4 hour shift.
(1c) The need to clarify as to the role an ANNP or SANNP has, whether in a nursing capacity or medical capacity, and how they are perceived by other staff.
2) The observations for children in transition or admitted to NICU are not recorded seamlessly nor are easily viewable whether on a chart or graph .
3) The nursing staff do not appear able to escalate concerns either
i) due to lack of clear care plans and escalation markers
ii) poor training particularly the SANNP and ANNP in the recognition of respiratory distress and PPHN
ii) a lack of empowerment indicating a lack of leadership.
4) The on going training undertaken of nursing staff in relation to PPHN and respiratory distress has been the responsibility of SANNP ████████ and a consultant, with no indication that they have undertaken training themselves.
5) Concern as to staff deciding whether a child in respiratory distress should be NBM or not and what is the guidance on this.
6) The Transfer policy for this Trust and what would be guidance or indicators as to the seeking of tertiary level assistance and transfer, especially when a crisis point may be reached past 10pm.
7) What is the current system in place for handovers between medical staff and nursing staff, whether written or verbal, and what information must be included as part of that handover.
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on NBM decisions for children in respiratory distress
Wider context from the report “(1a) Staffing levels over the weekend and bank holiday, in particular the use of ANNP and SANNP trained staff to replace junior and registrar level doctors on duty covering NICU.
(1b) The need for a dedicated junior level doctor or registrar to be on duty 24 hours covering NICU, and not a limited 3 / 4 hour shift.
(1c) The need to clarify as to the role an ANNP or SANNP has, whether in a nursing capacity or medical capacity, and how they are perceived by other staff.
2) The observations for children in transition or admitted to NICU are not recorded seamlessly nor are easily viewable whether on a chart or graph.
3) The nursing staff do not appear able to escalate concerns either
i) due to lack of clear care plans and escalation markers
ii) poor training particularly the SANNP and ANNP in the recognition of respiratory distress and PPHN
ii) a lack of empowerment indicating a lack of leadership.
4) The on going training undertaken of nursing staff in relation to PPHN and respiratory distress has been the responsibility of SANNP ████████ and a consultant, with no indication that they have undertaken training themselves.
5) Concern as to staff deciding whether a child in respiratory distress should be NBM or not and what is the guidance on this .
6) The Transfer policy for this Trust and what would be guidance or indicators as to the seeking of tertiary level assistance and transfer, especially when a crisis point may be reached past 10pm.
7) What is the current system in place for handovers between medical staff and nursing staff, whether written or verbal, and what information must be included as part of that handover.
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure trainers are themselves trained in PPHN and respiratory distress
Wider context from the report “(1a) Staffing levels over the weekend and bank holiday, in particular the use of ANNP and SANNP trained staff to replace junior and registrar level doctors on duty covering NICU.
(1b) The need for a dedicated junior level doctor or registrar to be on duty 24 hours covering NICU, and not a limited 3 / 4 hour shift.
(1c) The need to clarify as to the role an ANNP or SANNP has, whether in a nursing capacity or medical capacity, and how they are perceived by other staff.
2) The observations for children in transition or admitted to NICU are not recorded seamlessly nor are easily viewable whether on a chart or graph.
3) The nursing staff do not appear able to escalate concerns either
i) due to lack of clear care plans and escalation markers
ii) poor training particularly the SANNP and ANNP in the recognition of respiratory distress and PPHN
ii) a lack of empowerment indicating a lack of leadership.
4) The on going training undertaken of nursing staff in relation to PPHN and respiratory distress has been the responsibility of SANNP ████████ and a consultant, with no indication that they have undertaken training themselves .
5) Concern as to staff deciding whether a child in respiratory distress should be NBM or not and what is the guidance on this.
6) The Transfer policy for this Trust and what would be guidance or indicators as to the seeking of tertiary level assistance and transfer, especially when a crisis point may be reached past 10pm.
7) What is the current system in place for handovers between medical staff and nursing staff, whether written or verbal, and what information must be included as part of that handover.
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a defined medical and nursing handover system and required information
Wider context from the report “(1a) Staffing levels over the weekend and bank holiday, in particular the use of ANNP and SANNP trained staff to replace junior and registrar level doctors on duty covering NICU.
(1b) The need for a dedicated junior level doctor or registrar to be on duty 24 hours covering NICU, and not a limited 3 / 4 hour shift.
(1c) The need to clarify as to the role an ANNP or SANNP has, whether in a nursing capacity or medical capacity, and how they are perceived by other staff.
2) The observations for children in transition or admitted to NICU are not recorded seamlessly nor are easily viewable whether on a chart or graph.
3) The nursing staff do not appear able to escalate concerns either
i) due to lack of clear care plans and escalation markers
ii) poor training particularly the SANNP and ANNP in the recognition of respiratory distress and PPHN
ii) a lack of empowerment indicating a lack of leadership.
4) The on going training undertaken of nursing staff in relation to PPHN and respiratory distress has been the responsibility of SANNP ████████ and a consultant, with no indication that they have undertaken training themselves.
5) Concern as to staff deciding whether a child in respiratory distress should be NBM or not and what is the guidance on this.
6) The Transfer policy for this Trust and what would be guidance or indicators as to the seeking of tertiary level assistance and transfer, especially when a crisis point may be reached past 10pm.
7) What is the current system in place for handovers between medical staff and nursing staff, whether written or verbal, and what information must be included as part of that handover .
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear care plans and escalation markers
Wider context from the report “(1a) Staffing levels over the weekend and bank holiday, in particular the use of ANNP and SANNP trained staff to replace junior and registrar level doctors on duty covering NICU.
(1b) The need for a dedicated junior level doctor or registrar to be on duty 24 hours covering NICU, and not a limited 3 / 4 hour shift.
(1c) The need to clarify as to the role an ANNP or SANNP has, whether in a nursing capacity or medical capacity, and how they are perceived by other staff.
2) The observations for children in transition or admitted to NICU are not recorded seamlessly nor are easily viewable whether on a chart or graph.
3) The nursing staff do not appear able to escalate concerns either
i) due to lack of clear care plans and escalation markers
ii) poor training particularly the SANNP and ANNP in the recognition of respiratory distress and PPHN
ii) a lack of empowerment indicating a lack of leadership.
4) The on going training undertaken of nursing staff in relation to PPHN and respiratory distress has been the responsibility of SANNP ████████ and a consultant, with no indication that they have undertaken training themselves.
5) Concern as to staff deciding whether a child in respiratory distress should be NBM or not and what is the guidance on this.
6) The Transfer policy for this Trust and what would be guidance or indicators as to the seeking of tertiary level assistance and transfer, especially when a crisis point may be reached past 10pm.
7) What is the current system in place for handovers between medical staff and nursing staff, whether written or verbal, and what information must be included as part of that handover.
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate out-of-hours NICU staffing levels
Wider context from the report “(1a) Staffing levels over the weekend and bank holiday, in particular the use of ANNP and SANNP trained staff to replace junior and registrar level doctors on duty covering NICU .
(1b) The need for a dedicated junior level doctor or registrar to be on duty 24 hours covering NICU, and not a limited 3 / 4 hour shift.
(1c) The need to clarify as to the role an ANNP or SANNP has, whether in a nursing capacity or medical capacity, and how they are perceived by other staff.
2) The observations for children in transition or admitted to NICU are not recorded seamlessly nor are easily viewable whether on a chart or graph.
3) The nursing staff do not appear able to escalate concerns either
i) due to lack of clear care plans and escalation markers
ii) poor training particularly the SANNP and ANNP in the recognition of respiratory distress and PPHN
ii) a lack of empowerment indicating a lack of leadership.
4) The on going training undertaken of nursing staff in relation to PPHN and respiratory distress has been the responsibility of SANNP ████████ and a consultant, with no indication that they have undertaken training themselves.
5) Concern as to staff deciding whether a child in respiratory distress should be NBM or not and what is the guidance on this.
6) The Transfer policy for this Trust and what would be guidance or indicators as to the seeking of tertiary level assistance and transfer, especially when a crisis point may be reached past 10pm.
7) What is the current system in place for handovers between medical staff and nursing staff, whether written or verbal, and what information must be included as part of that handover.
” Open source report
10 Oct 2016 Ann Hardman · Prevention of Future Deaths report Isle of Wight
View report summary
Concerns raised 1 Failure to automatically arrange and communicate repeat DVT scanning after a negative scan View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ann Hardman · 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
Ann Hardman attended her GP with a painful swollen left calf and a positive D-Dimer test, but an ultrasound scan at St Mary’s Hospital was suboptimal because of technical limitations associated with her build. On 20 January 2015, after contacting her GP practice about chest pain, she declined advice to call 999 and was shortly afterwards found dead at home. The medical cause of death was pulmonary thromboembolism associated with thrombosis of the deep veins of the left calf. The concern was that the protocol relied on patients returning to their GP to obtain a further scan referral, rather than being automatically advised by the ultrasound department to attend a repeat scan.
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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to automatically arrange and communicate repeat DVT scanning after a negative scan
Wider context from the report “1. I am concerned that when there is a negative scan for a DVT at St Mary’s Hospital, the current protocol relies on the patient returning to their GP and being given another referral form for a further scan 6-8 days later . It was accepted that a better system would be one whereby the patient was automatically told to return for a further scan a week or so later by the ultrasound department , subject to the patient’s GP cancelling this scan, based on their clinical judgement of any review of the initial scan and/or any further examination of the patient. This would remove the chance of patients failing to be told to re-attend for a further scan .
” 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 Implement a follow-up system booking repeat ultrasound scans 6–8 days after a negative scan and notifying GP practices about non-attendance.
Verbatim wording from the response “I am therefore very pleased to report that we have implemented the following system in line with your suggestion:” Source location 2016-0350-Response-by-Isle-of-Wight-NHS-Trust
Open published response
24 Nov 2014 Lara Mamula · Prevention of Future Deaths report Isle of Wight
View report summary
Concerns raised 2 Failure to advise hospital assessment for suspected recurrent aortic dissection View source Lack of awareness of the serious aortic risks associated with Loeys-Dietz syndrome 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
Lara Mamula · 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
Lara Mamula had a history of aortic dissection and Loeys-Dietz syndrome. After developing chest pain similar to that experienced during her earlier dissection, she was assessed by ambulance staff and later attended A&E, where she was diagnosed with gastritis and discharged. Five days later, she was found deceased at home; concerns included that the ambulance service did not appreciate the seriousness of her condition or the significance of her recurrent pain, and that a CT scan was not undertaken.
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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to advise hospital assessment for suspected recurrent aortic dissection
Wider context from the report “1. During the course of the evidence, it became clear that the Isle of Wight Ambulance Service did not appreciate the gravity of the situation when they were called out by Mrs Mamula on 12th June 2013, inasmuch as they were not aware that Loeys-Dietz syndrome predisposes those who suffer from it to have repeated thoracic aortic aneurysms and dissections. Had they known that this condition was so grave and that Mrs Mamula was complaining of the same pain which she had suffered from 2 years previously which was clearly a very ominous symptom, they could have impressed on Mrs Mamula that she would have been much safer to have been taken to hospital at that point to be thoroughly checked out with a CT scan , which would have been the only definitive way to ascertain if she was suffering a new aortic dissection.
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the serious aortic risks associated with Loeys-Dietz syndrome
Wider context from the report “1. During the course of the evidence, it became clear that the Isle of Wight Ambulance Service did not appreciate the gravity of the situation when they were called out by Mrs Mamula on 12th June 2013, inasmuch as they were not aware that Loeys-Dietz syndrome predisposes those who suffer from it to have repeated thoracic aortic aneurysms and dissections . Had they known that this condition was so grave and that Mrs Mamula was complaining of the same pain which she had suffered from 2 years previously which was clearly a very ominous symptom, they could have impressed on Mrs Mamula that she would have been much safer to have been taken to hospital at that point to be thoroughly checked out with a CT scan, which would have been the only definitive way to ascertain if she was suffering a new aortic dissection.
” Open source report
12 Sep 2014 Barbara Monica May Cooke · Prevention of Future Deaths report Isle of Wight
View report summary
Concerns raised 6 Lack of a protocol for chasing up unresponded District Nurse Service messages View source Failure to recognise infection risks from leaving incontinent residents in their own waste View source Inadequate staffing levels for meeting residents’ care, medication, comfort and dignity needs View source Lack of admission recording of open safeguarding concerns View source Lack of automatic coroner referral for deaths of inpatients subject to safeguarding alerts View source Lack of automatic safeguarding-team notification of deaths of inpatients subject to open safeguarding alerts View source See 3 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
Barbara Monica May Cooke · 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
Barbara Monica May Cooke, an 84-year-old resident of Waxham House Residential Care Home, developed severe pressure ulcers, sepsis and multiple organ failure, and died in hospital on 11 April 2014. The report raised concerns about inadequate staffing, delays in toileting and cleaning, failure to recognise and manage infection risks associated with pressure sores, and gaps in communication and safeguarding procedures after her admission and death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol for chasing up unresponded District Nurse Service messages
Wider context from the report “3. I am concerned that there appears to be no protocol at Waxham House to chase up the District Nurse Service if they haven’t responded to a message within 24
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise infection risks from leaving incontinent residents in their own waste
Wider context from the report “2. I am concerned that the Waxham House Residential Care Home didn’t recognise the obvious risks of infection of leaving an incontinent lady sitting in her own waste when she was prone to sacral sores , and almost certainly had at least one at the point at which she was left sitting in her own urine and excrement for two and half hours on 30th March 2014.
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate staffing levels for meeting residents’ care, medication, comfort and dignity needs
Wider context from the report “1. During the course of the evidence, it became clear that the resident to staff ratio of 20:2 during between 2 p.m. and 9 p.m. was inadequate to deal with all the residents’ needs at Waxham House. (The staffing levels at other times also appeared inadequate for the numbers of residents .) The staffing levels did not allow for one staff member to safely distribute medication to the residents without interruption ; provide teas for the residents and cater for their other reasonable needs in an acceptable timeframe. I was concerned that residents were being left for two and a half hours, sitting in their own excrement, waiting to be taken to the toilet and cleaned, and that there were insufficient staff to attend to a resident who was clearly dying . Moreover, I am concerned that there were insufficient staff members to escort residents away from a resident who was being attended to by paramedics , thereby denying this lady any dignity in her last moments.
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of admission recording of open safeguarding concerns
Wider context from the report “4. I am concerned that there does not appear to be a system in place at St Mary’s Hospital to record on admission that a patient is the subject of an open Safeguarding concern . (In this case, the subject of the Safeguarding alert was an adult, but this concern relates to both adults and children.)
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of automatic coroner referral for deaths of inpatients subject to safeguarding alerts
Wider context from the report “5. I am further concerned that there is currently no system in place at St Mary’s Hospital to automatically contact the Coroner to refer the matter for investigation when a person who is the subject of a Safeguarding alert dies whilst an inpatient in the Hospital .
” 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 Isle of Wight NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of automatic safeguarding-team notification of deaths of inpatients subject to open safeguarding alerts
Wider context from the report “6. I am concerned that there is currently no system in place at St Mary’s Hospital to automatically notify the IOW Safeguarding Team if someone who is the subject of an open safeguarding alert dies whilst an inpatient in the Hospital .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations