14 Jan 2022 Alfie Stone · Prevention of Future Deaths report Northamptonshire
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Concerns raised 6 Failure to accept recommendations to carry and administer buccal midazolam when necessary View source Failure to ask parents whether the child had vomited View source Lack of paramedic training in the use of buccal midazolam View source Lack of evidence of paramedic training following an independent Serious Incident Report and agreed recommendations View source Failure to attempt alternative oxygenation View source Failure to attempt suction 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.
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AI-generated summary
Alfie Stone · 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
Alfie Stone, aged 12, died after prolonged seizures, status epilepticus, hypoxia and multiple organ failure following admission to hospital. Concerns included paramedics’ lack of training in buccal midazolam, inadequate oxygenation, no suction attempt, and insufficient evidence of training following an earlier Serious Incident Report.
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 Kettering General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to accept recommendations to carry and administer buccal midazolam when necessary
Wider context from the report “(5) East Midlands Ambulance Service were not accepting the recommendations 3 within the report to carry and administer Buccal Midazolam when necessary .
” 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 Kettering General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to ask parents whether the child had vomited
Wider context from the report “(3) No suction attempted and the question was not asked of the parents as to whether the child had vomited .
” 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 Kettering General Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of paramedic training in the use of buccal midazolam
Wider context from the report “(1) Apparent lack of training of paramedics in the use of Buccal Midazolam
” 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 Kettering General Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of evidence of paramedic training following an independent Serious Incident Report and agreed recommendations
Wider context from the report “(4) No evidence of training to the paramedics who attended and gave evidence following an independent Serious Incident Report and its agreed recommendations
” 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 Kettering General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to attempt alternative oxygenation
Wider context from the report “(2) No other form of oxygenation attempted such as bagging or the child being taken earlier to the ambulance to secure and deliver oxygen
” 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 Kettering General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to attempt suction
Wider context from the report “(3) No suction attempted and the question was not asked of the parents as to whether the child had vomited.
” Open source report
14 May 2018 Gladys Kathleen Rich · Prevention of Future Deaths report Northamptonshire
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Concerns raised 8 Lack of a mechanism to ensure safe delivery and discharge of Falls Prevention Service input View source Failure of the Falls Prevention Service to proactively follow up required input View source Failure to transmit and resubmit completed falls action plans through the required process View source Failure to use appropriate falls referral thresholds View source Unavailability of required falls prevention equipment View source Failure to consider and action falls risk action plan advice View source Failure to make new falls prevention referrals after further falls View source Failure to identify falls risks during pre-assessment View source See 5 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
Gladys Kathleen Rich · 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
Gladys Kathleen Rich suffered repeated falls after moving into Avenue House Nursing and Care Home, culminating in a fall on 28 December 2016 that caused traumatic subdural and subarachnoid haemorrhages and a skull fracture. She died on 3 March 2017; the medical cause of death included chest infection, intracranial haemorrhage and a fall, with rectal cancer and liver metastases also recorded. The principal concerns related to failures to identify and manage her falls risk, ineffective referral and follow-up by the care home and Falls Prevention Service, inadequate resources and equipment, and the absence of an effective system to ensure required falls-prevention input was delivered.
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 Kettering General Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism to ensure safe delivery and discharge of Falls Prevention Service input
Wider context from the report “3. There does not seem to be any mechanism for ensuring that Falls Prevention Service input is in fact delivered when it is required and that a patient is only ever discharged or that it is clear that the underlying symptoms causing the falls are resolved or that measures have been put in place to mitigate the falls risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Kettering General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of the Falls Prevention Service to proactively follow up required input
Wider context from the report “2. In relation to the Falls Prevention Service.
a) Despite Mrs Rich having been referred to the Falls Prevention Service by her GP and the service being notified of a fall related hospitalisation in August 2016, the onus was placed on the patient and her family to make a further appointment . In the absence of any further contact, the service assumes that their input is no longer required . As is clear in the case of Mrs Rich, the prevention service was very much still required. Again, when the service was contacted in November 2016 the failure to receive a form or a response to the subsequent letter again led to an automatic assumption that input was no longer required despite the fact that this was the second referral to have been made in relation to Mrs Rich. It was explained in evidence that the reason the service cannot be more proactive is because they are inadequately resourced .
” 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 Kettering General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to transmit and resubmit completed falls action plans through the required process
Wider context from the report “c) Once a referral was made, and a falls risk action plan was received the advice within does not appear to have been properly considered or actioned. Furthermore, the action plan was returned to the Falls Prevention Service by post rather than the required method of facsimile . Although the care home was notified that the Falls Prevention Service had not received the completed action plan, it was not resubmitted . Despite Mrs Rich then suffering a series of further falls, no new referrals were made to the Falls Prevention Service.
” 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 Kettering General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to use appropriate falls referral thresholds
Wider context from the report “b) The policy of waiting for 3 falls before making a referral seems to be arbitrary and also at odds with the Fall Prevention Service requirement of 1 fall within a 12 month period before a referral will be accepted .
” 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 Kettering General Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of required falls prevention equipment
Wider context from the report “d) The care home may not have some of the equipment that they require for patients such as Mrs Rich e.g. a bed sensor mat .
” 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 Kettering General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to consider and action falls risk action plan advice
Wider context from the report “c) Once a referral was made, and a falls risk action plan was received the advice within does not appear to have been properly considered or actioned . Furthermore, the action plan was returned to the Falls Prevention Service by post rather than the required method of facsimile. Although the care home was notified that the Falls Prevention Service had not received the completed action plan, it was not resubmitted. Despite Mrs Rich then suffering a series of further falls, no new referrals were made to the Falls Prevention Service.
” 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 Kettering General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to make new falls prevention referrals after further falls
Wider context from the report “c) Once a referral was made, and a falls risk action plan was received the advice within does not appear to have been properly considered or actioned. Furthermore, the action plan was returned to the Falls Prevention Service by post rather than the required method of facsimile. Although the care home was notified that the Falls Prevention Service had not received the completed action plan, it was not resubmitted. Despite Mrs Rich then suffering a series of further falls, no new referrals were made to the Falls Prevention Service .
” 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 Kettering General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to identify falls risks during pre-assessment
Wider context from the report “a) Failure to identify Mrs Rich as a falls risk during a pre-assessment process , despite the fact that she had sustained a fall requiring hospitalisation 9 months before. The pre-assessment check may not therefore be sufficiently robust .
” Open source report
16 Jun 2017 Mrs Macrae · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 2 Failure to seek attendance by the attending spinal surgeon for postoperative instability View source Failure to consider internal haemorrhage as a cause of instability after elective spinal surgery View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mrs Macrae · 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 Macrae was admitted for elective lumbar spinal surgery and experienced intermittent drops in blood pressure during recovery. The report raises concern that internal haemorrhage was not considered as a possible cause of her instability and that this rare but recognised complication should be understood after similar surgery.
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 Kettering General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to seek attendance by the attending spinal surgeon for postoperative instability
Wider context from the report “1) Mrs Macrae was admitted to the Woodlands Hospital Kettering on 11th June 2016 for routine left lumbar L4/L5 decompression and discectomy under the care of a specialist neurosurgeon. Whilst in recovery her blood pressure dropped on occasion. She was cared for by attending anaesthetists but her attending spinal surgeon was not asked to attend . Those caring for Mrs Macrae did not consider internal haemorrhage as a cause of her instability.
2) All persons having care for a patient having undergone a similar elective spinal surgery should be aware that internal haemorrhage is a rare but recognised complication of this surgery.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Kettering General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to consider internal haemorrhage as a cause of instability after elective spinal surgery
Wider context from the report “1) Mrs Macrae was admitted to the Woodlands Hospital Kettering on 11th June 2016 for routine left lumbar L4/L5 decompression and discectomy under the care of a specialist neurosurgeon. Whilst in recovery her blood pressure dropped on occasion. She was cared for by attending anaesthetists but her attending spinal surgeon was not asked to attend. Those caring for Mrs Macrae did not consider internal haemorrhage as a cause of her instability .
2) All persons having care for a patient having undergone a similar elective spinal surgery should be aware that internal haemorrhage is a rare but recognised complication of this surgery .
” 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