24 Jun 2025 Susan Nora Elizabeth YOUNG · Prevention of Future Deaths report Norfolk
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Concerns raised 3 Failure to secure patients' own medication View source Lack of clinical handover to receiving wards View source Failure to pass on doctors' instructions for cardiac monitoring View source
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Susan Nora Elizabeth 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
Susan Nora Elizabeth Young was admitted to hospital after taking overdoses of prescription medication on 22 and 23 August 2024. She was transferred to a ward with directions for cardiac monitoring, but no clinical handover or monitoring instructions were provided. She was later found unresponsive and not attached to monitoring, and resuscitation failed; unused medication was subsequently found among her belongings.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to James Paget University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to secure patients' own medication
Wider context from the report “NO clinical handover to receiving ward. No instructions passed on from the doctor re cardiac monitoring. Patients own medication found in her belongings which had been with her , after her death allowing her the opportunity to take another overdose.
” 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 James Paget University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical handover to receiving wards
Wider context from the report “NO clinical handover to receiving ward. No instructions passed on from the doctor re cardiac monitoring. Patients own medication found in her belongings which had been with her, after her death allowing her the opportunity to take another overdose.
” 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 James Paget University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to pass on doctors' instructions for cardiac monitoring
Wider context from the report “NO clinical handover to receiving ward. No instructions passed on from the doctor re cardiac monitoring. Patients own medication found in her belongings which had been with her, after her death allowing her the opportunity to take another overdose.
” 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 Develop and implement a standard ED-to-EADU handover process and form that includes specialist requirements such as cardiac monitoring.
Verbatim wording from the response “vi. As a Trust, we are developing a communication process for handover with a task and finish group commencing 23rd May 2025. This includes leads from each department including ED and EADU. The flow chart is in the design phase, with an aim to commence the new process mid-June. Specialist requirements for the patient including cardiac monitoring will be included in the handover template. Once embedded, an audit will take place to monitor compliance and identify gaps needing further education and support.” Source location Response from James Paget University Hospitals NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the updated Self-Harm Policy and patient-search procedure with Emergency Care staff and support acknowledgement of understanding.
Verbatim wording from the response “ii. Action C2 - To share the self-harm policy across Emergency Care with a reference to this patient safety incident once the addendum as above has been added.
I can confirm that the search policy has been shared with all ED clinical staff on the 16th April 2025 and was added to the self-harm policy as an addendum which is available on the intranet for all staff to access. Following this, a signatory list will be collected to ensure that all staff have read and understood the policy and its implications for patients presenting with self harm.” Source location Response from James Paget University Hospitals NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit the implemented ED Patient Handover Form monthly from September until consistent compliance is demonstrated.
Verbatim wording from the response “To support and evidence our addressing of all three matters of concern raised, we have included the updated Trust Transfer Policy, including the trust handover process which has been communicated and promoted to staff, the summary of the policy expectations that has been communicated to ED staff, evidence of the associated staff training undertaken and a copy of the ED Patient Handover Form now in use for all patient transfers. An audit of the implemented ED Patient Handover Form is scheduled in September and will be ongoing monthly until results demonstrate good and consistent compliance.” Source location Response from James Paget University Hospitals NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add a patient-search procedure to the Self-Harm Policy covering searches for medication and other items that could enable overdose or self-harm.
Verbatim wording from the response “I can confirm that the Trust's Self Harm Policy (copy attached) now includes an addendum (Appendix C) an SOP (Standard Operating Procedure) Search of Patients within the ED. The policy describes the rationale behind searching patients attending the ED in Mental Health crisis to reduce the risk of patients attempting further overdose or self-harm during their time in the ED. The updated policy has been uploaded to the Trust's intranet.” Source location Response from James Paget University Hospitals NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit compliance with the ED patient handover form monthly after the scheduled September audit until consistent compliance is demonstrated.
Verbatim wording from the response “To support and evidence our addressing of all three matters of concern raised, we have included the updated Trust Transfer Policy, including the trust handover process which has been communicated and promoted to staff, the summary of the policy expectations that has been communicated to ED staff, evidence of the associated staff training undertaken and a copy of the ED Patient Handover Form now in use for all patient transfers. An audit of the implemented ED Patient Handover Form is scheduled in September and will be ongoing monthly until results demonstrate good and consistent compliance.” Source location Response from James Paget University NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the updated Self Harm Policy and patient-search procedure to Emergency Care staff and promote its requirements through written and face-to-face communication.
Verbatim wording from the response “C2 Action Required – Local
To share the self-harm policy across Emergency Care with a reference to this patient safety incident once the addendum as above has been added.
Responsibility: Matron Urgent Care
Timescale: 30th July 2025
RAG: W” Source location Response from James Paget University NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the ED patient handover process and form for transfers, including communication of cardiac monitoring and other specialist requirements.
Verbatim wording from the response “vi. As a Trust, we are developing a communication process for handover with a task and finish group commencing 23rd May 2025. This includes leads from each department including ED and EADU. The flow chart is in the design phase, with an aim to commence the new process mid-June. Specialist requirements for the patient including cardiac monitoring will be included in the handover template. Once embedded, an audit will take place to monitor compliance and identify gaps needing further education and support.” Source location Response from James Paget University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add a patient-search procedure to the Self Harm Policy, covering removal and safe storage of medications and other harmful items in Emergency Department patients at risk.
Verbatim wording from the response “C1 Action Required – Local
To complete the agreed process for searching patients to maintain patient safety (this will form an addendum to the self-harm policy).
Responsibility: Matron Mental Health Liaison / Consultant
Timescale: 30th June 2025
RAG: A” Source location Response from James Paget University NHS Foundation Trust
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8 Jan 2024 Sarah Julie MITCHELL · Prevention of Future Deaths report Suffolk
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Concerns raised 2 Failure to limit medication dispensing in line with overdose-risk controls View source Lack of accident and emergency staff access to medication records and dispensing rationale 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
Sarah Julie MITCHELL · 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
Sarah Julie MITCHELL, who had a history of chronic back pain, medication dependence, and previous overdoses, was found deceased at her residence on 22 September 2022. The post-mortem found multiple drug toxicity from prescribed medication. The principal concerns were that she received 28 days’ worth of medication in less than 48 hours despite known overdose and hoarding risks, and that emergency department staff had no process for accessing relevant medication records and dispensing information.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to James Paget University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to limit medication dispensing in line with overdose-risk controls
Wider context from the report “The provision to Ms. MITCHELL of 28 days’ worth of prescribed medication in less than a 48-hour period (14 days’ worth of medication dispensed on each occasion she was discharged hospital on the 3rd and 4th of August 2022). This occurred at a time when, due to concerns about Ms. MITCHELL hoarding medication and taking an overdose, she was receiving weekly medication prescriptions from her GP to control this risk .
The evidence heard at Inquest indicated that there was no process in place whereby accident and emergency staff could access Ms. MITCHELL’s medical records detailing the medication she was receiving and the rationale behind the dispensing regime in place.
” 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 James Paget University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of accident and emergency staff access to medication records and dispensing rationale
Wider context from the report “The provision to Ms. MITCHELL of 28 days’ worth of prescribed medication in less than a 48-hour period (14 days’ worth of medication dispensed on each occasion she was discharged hospital on the 3rd and 4th of August 2022). This occurred at a time when, due to concerns about Ms. MITCHELL hoarding medication and taking an overdose, she was receiving weekly medication prescriptions from her GP to control this risk.
The evidence heard at Inquest indicated that there was no process in place whereby accident and emergency staff could access Ms. MITCHELL’s medical records detailing the medication she was receiving and the rationale behind the dispensing regime in place .
” 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 Procure a shared electronic patient-record system across the three acute trusts.
Verbatim wording from the response “Next Steps
You may be aware that the Norfolk and Waveney Acute Hospital Collaborative are in the process of procuring an Electronic Patient Record system for use across the three acute Trusts. This will remove the need for separate systems, including EPMA and e-Discharge and will eliminate the issues of data transfer between systems.” Source location Response from James Paget University Hospitals NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that 28 days of medication were supplied, stating that the first discharge involved only a 10-day fluoxetine supply.
Verbatim wording from the response “Provision of Prescribed Medication
I have received assurance from the Trust’s Chief Pharmacist that the only medication which Ms Mitchell was given upon her first discharge, on 3rd August 2022, was one box of Fluoxetine ████████ capsules, equating to a 10 day supply. This is evidenced in the Trust’s dispensing record for this patient as illustrated below:” Source location Response from James Paget University Hospitals NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that emergency department staff lacked access to relevant medical records, stating that staff could access Summary Care Record and SystmOne.
Verbatim wording from the response “Summary Care Record (SCR) is a national database that holds electronic records of important patient information such as current medication, allergies and details of any previous adverse reactions to medicines, created from the GP medical records. It can be seen and used by authorised staff in other areas of the health and care system involved in the patient’s direct care.” Source location Response from James Paget University Hospitals NHS Foundation Trust
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24 Dec 2019 Ifeoma Onwuka · Prevention of Future Deaths report Norfolk
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Concerns raised 5 Lack of clinical leadership and oversight of care View source Lack of professional curiosity about the cause of DIC View source Lack of on-call consultant capability to perform emergency surgery independently View source Reluctance of the on-call consultant to consider non-conservative management View source Lack of ability to work in or lead a clinical team 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.
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AI-generated summary
Ifeoma Onwuka · 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
Mrs Onwuka was admitted for induction of labour and developed severe bleeding and disseminated intravascular coagulopathy after delivering her baby. She underwent a hysterectomy after a delay, and an expert concluded that the delay in surgery to control the bleeding contributed to her death. The principal concerns were apparent lack of confidence in performing emergency hysterectomy, inadequate investigation of the cause of the coagulopathy, and lack of leadership and overview of her care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to James Paget University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical leadership and oversight of care
Wider context from the report “1. Apparent lack of confidence/ability on part of on-call consultant to perform an emergency total abdominal hysterectomy without another consultant present.
2. Lack of professional curiosity about cause of DIC, the haemorrhage was not enough to cause this.
3. Lack of leadership and overview of Mrs Onwuka’s care . Reluctance on the part of the on-call consultant to consider anything other than conservative measures until another obstetric consultant was present.
That pregnant women in the area served by this hospital may be at risk if emergency surgery is needed and this consultant has these apparent difficulties, continues with an apparent lack of professional curiosity and displays no evidence of the ability to work in a team or head a team .
” 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 James Paget University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of professional curiosity about the cause of DIC
Wider context from the report “1. Apparent lack of confidence/ability on part of on-call consultant to perform an emergency total abdominal hysterectomy without another consultant present.
2. Lack of professional curiosity about cause of DIC , the haemorrhage was not enough to cause this.
3. Lack of leadership and overview of Mrs Onwuka’s care. Reluctance on the part of the on-call consultant to consider anything other than conservative measures until another obstetric consultant was present.
That pregnant women in the area served by this hospital may be at risk if emergency surgery is needed and this consultant has these apparent difficulties, continues with an apparent lack of professional curiosity and displays no evidence of the ability to work in a team or head a team.
” 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 James Paget University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of on-call consultant capability to perform emergency surgery independently
Wider context from the report “1. Apparent lack of confidence/ability on part of on-call consultant to perform an emergency total abdominal hysterectomy without another consultant present.
2. Lack of professional curiosity about cause of DIC, the haemorrhage was not enough to cause this.
3. Lack of leadership and overview of Mrs Onwuka’s care. Reluctance on the part of the on-call consultant to consider anything other than conservative measures until another obstetric consultant was present.
That pregnant women in the area served by this hospital may be at risk if emergency surgery is needed and this consultant has these apparent difficulties , continues with an apparent lack of professional curiosity and displays no evidence of the ability to work in a team or head a team.
” 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 James Paget University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reluctance of the on-call consultant to consider non-conservative management
Wider context from the report “1. Apparent lack of confidence/ability on part of on-call consultant to perform an emergency total abdominal hysterectomy without another consultant present.
2. Lack of professional curiosity about cause of DIC, the haemorrhage was not enough to cause this.
3. Lack of leadership and overview of Mrs Onwuka’s care. Reluctance on the part of the on-call consultant to consider anything other than conservative measures until another obstetric consultant was present.
That pregnant women in the area served by this hospital may be at risk if emergency surgery is needed and this consultant has these apparent difficulties, continues with an apparent lack of professional curiosity and displays no evidence of the ability to work in a team or head a team.
” 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 James Paget University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of ability to work in or lead a clinical team
Wider context from the report “1. Apparent lack of confidence/ability on part of on-call consultant to perform an emergency total abdominal hysterectomy without another consultant present.
2. Lack of professional curiosity about cause of DIC, the haemorrhage was not enough to cause this.
3. Lack of leadership and overview of Mrs Onwuka’s care. Reluctance on the part of the on-call consultant to consider anything other than conservative measures until another obstetric consultant was present.
That pregnant women in the area served by this hospital may be at risk if emergency surgery is needed and this consultant has these apparent difficulties, continues with an apparent lack of professional curiosity and displays no evidence of the ability to work in a team or head a team .
” Open source report
24 Mar 2015 Michael Barry Richardson · Prevention of Future Deaths report Norfolk
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Concerns raised 1 Failure to review admission records and follow up relevant information 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
Michael Barry Richardson · 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
Michael Barry Richardson was admitted to hospital on 24 October 2013 after deterioration in his lung disease and died on 27 October 2013 following an arrest. An ambulance report recorded that he had not eaten for five days, but this information may not have been reviewed during his MUST screening. The concern was that failure to review ambulance and other admission records could lead to missed information and pose a risk of future deaths.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to James Paget University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review admission records and follow up relevant information
Wider context from the report “There was within Mr Richardson's records an ambulance crew report which recorded that Mr Richardson was said to have not eaten for 5 days. In evidence before me it was confirmed that the ambulance report would have been available to the person who undertook the MUST screen. It also appeared that this may not have been reviewed at the time. If it had been reviewed the evidence given before me was to the effect that the information might have led to a MUST score of 2 which would in turn have led to a referral to dietician services. Although the expert evidence was that Mr Richardson's nutrition did not play a material part in his death, I am nevertheless concerned that in different circumstances a failure to follow up information or review the ambulance record and/or any other records with which a patient is admitted and so miss the information could affect the outcome for the patient and that there is therefore a risk of future deaths.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations