7 Apr 2026 Mark Robert Smith · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 9 Failure to ensure truthful observation records View source Failure to maintain QEH staff awareness of the limits of prison healthcare View source Failure to coordinate prison discharge through an MDT and relevant prison healthcare liaison View source Failure to prescribe and administer medication at the correct dose View source Failure to ensure safe and clearly understood medication-system operation View source Failure to record the cell-entry escalation process in policy View source Failure to maintain prison and healthcare staff awareness of the cell-entry escalation process View source Failure to complete required patient observations View source Unavailability of larger disabled cells adapted for constant watch View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mark Robert Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mark Robert Smith, who was detained at HMP Thameside, died after an epileptic seizure led to cardiac arrest. The report describes concerns about medication prescribing and administration, hospital-to-prison discharge and communication, access to his cell, observation arrangements and records, staffing, and the lack of equipment for resuscitation.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure truthful observation records
Wider context from the report “(5) I am concerned there were numerous missed and falsified observation entries in Mark’s case and how similar incidents can be prevented given the reliance on handwritten sheets being scanned onto the system at a later stage . I appreciate the efforts made with training and audits. (Practice Plus Group)
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain QEH staff awareness of the limits of prison healthcare
Wider context from the report “(2) I remain concerned a similar situation could arise as did in Mark’s case regarding a discharge back to prison from QEH without an MDT meeting despite repeated requests from prison healthcare and there could be a risk to life. I note PFD evidence provided regarding improved liaison between QEH and the prison GP but note no reference to liaison between QEH and the head of the healthcare in prison, who visited QEH twice in Mark’s case.
Further, as recently as 2025 an incident occurred when there was a lack of understanding at QEH around the limited provision in healthcare in prison . I am concerned as to how awareness of the limits of prison healthcare will be disseminated on a continuing basis to new and locum staff at QEH . (QEH and Practice Plus Group)
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate prison discharge through an MDT and relevant prison healthcare liaison
Wider context from the report “(2) I remain concerned a similar situation could arise as did in Mark’s case regarding a discharge back to prison from QEH without an MDT meeting despite repeated requests from prison healthcare and there could be a risk to life. I note PFD evidence provided regarding improved liaison between QEH and the prison GP but note no reference to liaison between QEH and the head of the healthcare in prison , who visited QEH twice in Mark’s case.
Further, as recently as 2025 an incident occurred when there was a lack of understanding at QEH around the limited provision in healthcare in prison. I am concerned as to how awareness of the limits of prison healthcare will be disseminated on a continuing basis to new and locum staff at QEH. (QEH and Practice Plus Group)
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prescribe and administer medication at the correct dose
Wider context from the report “(1) The wrong dose of medication could be prescribed and/or administered with life threatening consequences. Albeit I have seen evidence of significant improvements in prescribing practice at HMP Thameside since 2019 (e.g HMIP report February 2026); as recently as 2024 to 2025 HMIP and IMB reports noted “significant risks with management of medicines” and “prescribing errors.” Whilst recent internal audits in 2025 show significant improvements, medication incidents (datix) are recorded in late 2025 and the principal pharmacist notes a very busy site with multiple prescriptions screened daily.
Further, during the inquest it proved difficult to establish how Systm 1 (the medical note system) operated and whether there were risks inherent in the system itself. For example, it was suggested the system would convert mg into ml or pre-populate entries such as 100ml, in contradiction to the subsequent PFD evidence provided. (Practice Plus Group)
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure safe and clearly understood medication-system operation
Wider context from the report “(1) The wrong dose of medication could be prescribed and/or administered with life threatening consequences. Albeit I have seen evidence of significant improvements in prescribing practice at HMP Thameside since 2019 (e.g HMIP report February 2026); as recently as 2024 to 2025 HMIP and IMB reports noted “significant risks with management of medicines” and “prescribing errors.” Whilst recent internal audits in 2025 show significant improvements, medication incidents (datix) are recorded in late 2025 and the principal pharmacist notes a very busy site with multiple prescriptions screened daily.
Further, during the inquest it proved difficult to establish how Systm 1 (the medical note system) operated and whether there were risks inherent in the system itself . For example, it was suggested the system would convert mg into ml or pre-populate entries such as 100ml , in contradiction to the subsequent PFD evidence provided. (Practice Plus Group)
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record the cell-entry escalation process in policy
Wider context from the report “(3) Healthcare staff may be unable to enter a prisoner’s cell at night and monitor them in a situation which may not constitute a “medical emergency” but in which a patient nevertheless requires attention; a patient could decline and the situation become life threatening. I have received detail from Serco of “an escalation process” if Oscar 1 and Hotel 1 cannot agree about entry to a cell and I have been told this has been “recommunicated” to all staff. However, this is not recorded in a policy. I am concerned about awareness of the process for all prison and healthcare staff including on an ongoing basis. (Serco and Practice Plus Group).
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain prison and healthcare staff awareness of the cell-entry escalation process
Wider context from the report “(3) Healthcare staff may be unable to enter a prisoner’s cell at night and monitor them in a situation which may not constitute a “medical emergency” but in which a patient nevertheless requires attention; a patient could decline and the situation become life threatening. I have received detail from Serco of “an escalation process” if Oscar 1 and Hotel 1 cannot agree about entry to a cell and I have been told this has been “recommunicated” to all staff. However, this is not recorded in a policy. I am concerned about awareness of the process for all prison and healthcare staff including on an ongoing basis. (Serco and Practice Plus Group).
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete required patient observations
Wider context from the report “(5) I am concerned there were numerous missed and falsified observation entries in Mark’s case and how similar incidents can be prevented given the reliance on handwritten sheets being scanned onto the system at a later stage. I appreciate the efforts made with training and audits. (Practice Plus Group)
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of larger disabled cells adapted for constant watch
Wider context from the report “(4) There are no larger disabled cells (which can accommodate hospital beds and wheelchairs) adapted to also facilitate a constant watch. Security concerns, in this might not be possible, and a similar situation might occur to that in Mark’s case. (HMPPS)
” Open source report
14 Oct 2025 Paula Doreen Hughes · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Failure to prevent concurrent prescriptions of paracetamol-containing drugs View source Lack of robust mechanisms to mitigate confirmation bias and encourage professional curiosity View source Lack of a mechanism for consistently recording pre-admission over-the-counter medications View source Insufficient guidance for accurate and consistent assessment of the ACVPU confusion element View source Lack of guidance or policy for deciding when virtual reviews can replace face-to-face reviews View source Lack of a robust process for managing therapeutic excess and potential toxicity View source Risk of loss or dilution of prescribing safety nets during electronic system changes View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Paula Doreen Hughes · 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
Paula Doreen Hughes was admitted to hospital after a fall and received paracetamol in excess of the recommended dose because paracetamol was prescribed alongside co-codamol. The overdose was not recognised until she had developed fulminant acute liver failure, and timely treatment was not provided. The principal concerns included preventing duplicate paracetamol prescriptions and administration, recognising and managing therapeutic excess, accurately assessing confusion, recording over-the-counter medicines, mitigating confirmation bias, and providing guidance for virtual patient reviews.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent concurrent prescriptions of paracetamol-containing drugs
Wider context from the report “1. In respect of preventing concurrent prescriptions of paracetamol containing drugs and otherwise preventing prescribing errors resulting in therapeutic excess of paracetamol (NHSE, RPS, Cerner, MHRA, LGT)
(1) NHSE, RPS, Cerner, MHRA
I consider that the risk of concurrent prescriptions of paracetamol containing drugs is of wider national concern.
The Cerner prescribing system offers a duplicate checking functionality that is not a standard feature. It is hard stop and can be overridden and was not adopted by the LGT when the system was introduced. All the healthcare professionals were aware that co-codamol contained paracetamol and should not be prescribed with paracetamol. However, the 2 prescribing doctors failed to recognise that Mrs Hughes was already prescribed a paracetamol containing drug. 2 nurses failed to recognise they were administering 2 paracetamol containing drugs. A pharmacist failed to identify the concurrent prescriptions during reconciliation.
(2) LGT
LGT’s response to the incident was swift and commendable. A hard stop was introduced to the electronic prescribing system which eliminated concurrent prescriptions of paracetamol containing drugs. Further refinements of the system significantly reduced therapeutic excesses of paracetamol based on weight, which had been identified as an issue when investigating Mrs Hughes’ death. However, it is my understanding that consideration is being given to changing the electronic record and prescribing system. My concern is that during any move to a new system, the safety nets introduced by the Trust will be diluted or lost.
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of robust mechanisms to mitigate confirmation bias and encourage professional curiosity
Wider context from the report “5. Trust approach to mitigating against confirmation bias and encouraging professional curiosity (LGT)
Confirmation bias and a lack of professional curiosity were significant features in Mrs Hughes’ being administered two paracetamol containing drugs at the same time and in not investigating whether she had received a therapeutic excess and suffered consequential harm. I have found that the Trust does not have robust mechanism for mitigating against confirmation bias and encouraging professional curiosity.
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for consistently recording pre-admission over-the-counter medications
Wider context from the report “4. Mechanism for recording over the counter medications taken prior to attendance at the Emergency Department (LGT)
This concern has arisen out of my finding that Mrs Hughes had taken an over the counter (OTC) drug containing paracetamol before her admission to hospital but that this had not been recorded as part of her medication history. The Trust’s Medicines Reconciliation Policy requires that patients should be asked about OTCs. The Trust relies on individual clinical practice. There is no mechanism to ensure that pre-admission OTCs are consistently recorded such that the risk of therapeutic excess of paracetamol (or other drugs available OTC) in those circumstances continues to exist.
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance for accurate and consistent assessment of the ACVPU confusion element
Wider context from the report “3. The assessment of the ACVPU score (LGT, RCP, NHSE)
This concern has arisen out of the fact that Mrs Hughes was scored as alert when she was confused. Confusion would have added a score of 3 to her NEWS2 score and would have resulted in an earlier escalation of her condition. I heard that confusion is not always easy to identify and that the signs can be subtle.
(1) LGT
The Trust provided training materials relating to detection and management of deteriorating patients. There was minimal guidance on how to accurately assess the ACVPU score and the confusion element in particular. There remains a tangible risk that the ACVPU score will continue to be assessed inconsistently, with new episodes of confusion continuing to be missed.
(2) NHSE, RCP
I consider that consistent and accurate assessment of the ACVPU element of the NEWS2 score is likely to a matter of wider concern. This concern is being brought to the attention of NHSE and the RCP as I consider that they have the power to support healthcare professionals to ensure consistent and accurate scoring of confusion.
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance or policy for deciding when virtual reviews can replace face-to-face reviews
Wider context from the report “6. Trust policy on managing virtual patient reviews (LGT)
This concern has arisen out of the fact that Mrs Hughes had been reviewed virtually rather than face to face a resident doctor on the morning before she became unwell. The Trust has no guidance or policy on virtual reviews. I was told that this is a matter of clinical judgment. The absence of any guidance to help a still relatively inexperienced resident doctor decide when they can dispense with a face-to-face review is a circumstance that creates a risk that future deaths may occur.
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust process for managing therapeutic excess and potential toxicity
Wider context from the report “2. Management of therapeutic excess if it has not been prevented (LGT)
This issue has arisen from the finding that once the concurrent prescription had been identified, there had no attempt to consider whether there had been a therapeutic excess and whether Mrs Hughes had suffered harm. The Trust’s response to the incident focused on prevention. It did not consider the adequacy of the clinical response once the overdose had been identified. The Trust relies on information sharing of learning from incidents and thereafter places reliance on individual clinical practice. I received no evidence of a robust process for ensuring a consistent clinical response to the management of therapeutic excess and the potential for toxicity.
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Risk of loss or dilution of prescribing safety nets during electronic system changes
Wider context from the report “1. In respect of preventing concurrent prescriptions of paracetamol containing drugs and otherwise preventing prescribing errors resulting in therapeutic excess of paracetamol (NHSE, RPS, Cerner, MHRA, LGT)
(1) NHSE, RPS, Cerner, MHRA
I consider that the risk of concurrent prescriptions of paracetamol containing drugs is of wider national concern.
The Cerner prescribing system offers a duplicate checking functionality that is not a standard feature. It is hard stop and can be overridden and was not adopted by the LGT when the system was introduced. All the healthcare professionals were aware that co-codamol contained paracetamol and should not be prescribed with paracetamol. However, the 2 prescribing doctors failed to recognise that Mrs Hughes was already prescribed a paracetamol containing drug. 2 nurses failed to recognise they were administering 2 paracetamol containing drugs. A pharmacist failed to identify the concurrent prescriptions during reconciliation.
(2) LGT
LGT’s response to the incident was swift and commendable. A hard stop was introduced to the electronic prescribing system which eliminated concurrent prescriptions of paracetamol containing drugs. Further refinements of the system significantly reduced therapeutic excesses of paracetamol based on weight, which had been identified as an issue when investigating Mrs Hughes’ death. However, it is my understanding that consideration is being given to changing the electronic record and prescribing system. My concern is that during any move to a new system, the safety nets introduced by the Trust will be diluted or lost.
” 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 Deliver ward-staff refresher training on recognising deterioration, escalation and accurate ACVPU assessment.
Verbatim wording from the response “(ii) Refresher Training for Ward Staff
All clinical staff on the ward where the patient was admitted will complete refresher training on recognising and escalating the deteriorating patient, with a specific focus on accurate ACVPU assessment. This will help ensure consistent and reliable NEWS scoring across the team.” Source location Response from Lewisham and Greenwich NHS 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 Edit internal professional standards locally and work with virtual-ward providers to improve safety around virtual reviews.
Verbatim wording from the response “This will no doubt become more important and there is ongoing work with an intention to edit the IPS locally, and work with the Virtual Ward providers to maximise safety around virtual review.” Source location Response from Lewisham and Greenwich NHS 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 Review and revise the Adult Deteriorating Patient Policy to incorporate relevant guidance and clear ACVPU assessment instructions.
Verbatim wording from the response “(iv) Review of the Adult Deteriorating Patient Policy
The Lead Practice Development Nurse, the Trust Resuscitation Lead and Consultant Lead for Deteriorating Patients will review and revise the Trust’s Adult Deteriorating Patient Policy to ensure the inclusion of relevant Royal College of Physicians guidance and clear instructions for assessing ACVPU, including how to identify subtle confusion.” Source location Response from Lewisham and Greenwich NHS 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 Develop and provide staff with a clinical guideline for managing paracetamol overdose and therapeutic excess.
Verbatim wording from the response “2. Management of therapeutic excess if it has not been prevented
The iCare system has an approved protocol available for paracetamol overdose (screenshots attached). This is the Scottish and Newcastle Anti-emetic Pre-treatment (SNAP) protocol. We recognise that a clinical guideline would help clinicians to identify whether this is required or not, and this is not something that currently exists at LGT. We will develop a clinical guideline for the management of paracetamol overdose in due course, that will be available to all Trust staff, to include a robust clinical response to the management of therapeutic excess and the potential for toxicity.” Source location Response from Lewisham and Greenwich NHS 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 Create a Medicines Reconciliation Quick Reference Guide for Emergency Department staff covering information sources and over-the-counter medicine prompts.
Verbatim wording from the response “• A Medicines Reconciliation Quick Reference Guide for ED staff highlighting sources of information and including prompt for OTC products” Source location Response from Lewisham and Greenwich NHS 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 Seek assurance that Epic will implement iCare paracetamol safety features when introduced across the three Trusts.
Verbatim wording from the response “In May 2027, the Trust will be joining Epic, an electronic records and prescribing system shared by our neighbouring Trusts, Guy’s and St Thomas’ NHS Foundation Trust (GSTT) and King’s College Hospital NHS Foundation Trust (KCH).” Source location Response from Lewisham and Greenwich NHS 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 Maintain electronic prescribing alerts preventing duplicate or excessive paracetamol prescribing and administration.
Verbatim wording from the response “There are several safety elements incorporated into the Lewisham and Greenwich NHS Trust (LGT) electronic prescribing and medicines administration (EPMA) system, iCare. This includes a ‘hard stop’ on prescribing concomitant paracetamol containing products and a number of ‘soft stops’ as listed below:” Source location Response from Lewisham and Greenwich NHS 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 Develop guidance for safe virtual patient reviews using national guidance.
Verbatim wording from the response “The Trust is developing guidance on virtual reviews using the NHS guidance (https://www.england.nhs.uk/long-read/remote-consulting/) [updated by NHSE in March 2025]. This guidance relates to full patient reviews as part of clinic appointments/virtual wards, however the guidance can also be transposed to telephone referrals/reviews.” Source location Response from Lewisham and Greenwich NHS 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 Disseminate virtual-review safety expectations, risks and escalation routes through patient-safety bulletins.
Verbatim wording from the response “The Trust will disseminate the above by way of patient safety bulletins, the need for vigilance around virtual review and advise staff of the dangers of it and the clear routes for escalation if they are not satisfied with the response.” Source location Response from Lewisham and Greenwich NHS 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 Present the case for patient-safety discussion and learning about confirmation bias.
Verbatim wording from the response “Learning from patient safety incidents is embedded at LGT at a local (weekly incident teaching) and at an organisational level. The October 2025 Patient Safety Group has presented this case for discussion and learning specifically regarding whether confirmation bias played a role in Ms Hughes’ care. This case will also be shared in Grand Round and with medical students in 2025/26.” Source location Response from Lewisham and Greenwich NHS 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 Increase deteriorating-patient training completion across relevant clinical areas during 2026/27 compared with the 2025 baseline.
Verbatim wording from the response “(iii) Improvement in Training Compliance Trust-wide
The Trust will increase the number of staff completing deteriorating patient training across all relevant clinical areas during 2026/27, compared with the 2025 baseline. This will support a broader uplift in staff knowledge and skills relating to the identification of patient deterioration, including cognitive change.” Source location Response from Lewisham and Greenwich NHS 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 Oversee and monitor compliance and effectiveness of new virtual-review processes through quality governance structures.
Verbatim wording from the response “Ensuring compliance and the effectiveness of new processes will be overseen and monitored by the Trust via its governance structures for quality. We would like to assure you that Lewisham and Greenwich NHS Trust have taken the concerns raised seriously and learning from this incident will be shared and overseen by the Quality and Patient Safety Committee.” Source location Response from Lewisham and Greenwich NHS 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 Amend Emergency Department and ambulance handover documentation to prompt recording of over-the-counter medicines.
Verbatim wording from the response “Some actions identified through discussion with senior pharmacy staff to address some of the challenges of completing a medicines reconciliation in the Emergency Department (ED) are as follows:” Source location Response from Lewisham and Greenwich NHS 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 Review and update deteriorating-patient training with clearer ACVPU guidance, case scenarios and recognition of subtle confusion.
Verbatim wording from the response “The Trust acknowledges the concerns raised by the Coroner regarding the inaccurate assessment of ACVPU in this case, the associated impact on NEWS scoring, and the risk this poses to timely escalation of a deteriorating patient. We recognise that assessment of confusion can be subtle and subjective, and that training and policy must clearly support staff to identify even early or mild indicators of altered cognition. In direct response to the Coroner’s concerns, the following actions have been agreed by the Senior Nursing leadership team:” Source location Response from Lewisham and Greenwich NHS 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 Assess options for adding over-the-counter medicine prompts and fields to iCare pharmacy medication-history processes.
Verbatim wording from the response “• There are some options for reviewing pharmacy specific processes on iCare in relation to documenting the use of OTC products that the Trust will explore. The feasibility of these options and an appraisal of these would be required, including:
o Introduce a question: ‘The patient has been asked about OTC products’ and a yes/no button as part of Pharmacy Medication History. This would act as a prompt for those completing medication histories to specifically ask about OTC products
o Include the field, ‘OTC medication – yes/no/NA’ as part of ‘Document Medication by History’ form. This would allow the documentation of regularly used OTC items to be included as part of the medication history.” Source location Response from Lewisham and Greenwich NHS 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 Disseminate learning and required changes from the recently reviewed internal professional standards through the leadership exercise.
Verbatim wording from the response “Internal professional standards (IPS) are a key part of the review process. The Trust have reviewed their IPS very recently and are participating in a leadership exercise on this topic with dissemination to all staff on any learning/changes required. This is being done in conjunction with Getting It Right First Time (GIRFT) as part of a wider exercise on efficiency and safety and led by the medical directorate. There are now many systems within the NHS (as part of the wider NHS desire for streamlined pathways and community interface) that support virtual review (e.g. virtual ward) and whilst they are not directly relevant to this case, it is accepted that we do not need to always review face to face as long as adequate information is shared and there is an escalation process.” Source location Response from Lewisham and Greenwich NHS 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 Review medicines-reconciliation policies and checklists to clarify discussion and documentation of over-the-counter medicines and ambulance handover information.
Verbatim wording from the response “• Review the Medicines Reconciliation Policy” Source location Response from Lewisham and Greenwich NHS 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 learning from the case about confirmation bias and professional curiosity through Grand Round and medical-student teaching.
Verbatim wording from the response “Learning from patient safety incidents is embedded at LGT at a local (weekly incident teaching) and at an organisational level. The October 2025 Patient Safety Group has presented this case for discussion and learning specifically regarding whether confirmation bias played a role in Ms Hughes’ care. This case will also be shared in Grand Round and with medical students in 2025/26.” Source location Response from Lewisham and Greenwich 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 Review escalation processes for advice-giving and requesting senior input or face-to-face assessment.
Verbatim wording from the response “Staff are encouraged to escalate if there is disagreement on the need for a face-to-face review. The organisation is currently reviewing escalation processes around advice giving, recognising that it is key for staff to be able to escalate if they feel a patient requires more senior input or a face-to-face assessment for example.” Source location Response from Lewisham and Greenwich NHS 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 Face-to-face review is not always necessary where adequate information is shared and an escalation process exists.
Verbatim wording from the response “Internal professional standards (IPS) are a key part of the review process. The Trust have reviewed their IPS very recently and are participating in a leadership exercise on this topic with dissemination to all staff on any learning/changes required. This is being done in conjunction with Getting It Right First Time (GIRFT) as part of a wider exercise on efficiency and safety and led by the medical directorate. There are now many systems within the NHS (as part of the wider NHS desire for streamlined pathways and community interface) that support virtual review (e.g. virtual ward) and whilst they are not directly relevant to this case, it is accepted that we do not need to always review face to face as long as adequate information is shared and there is an escalation process.” Source location Response from Lewisham and Greenwich NHS 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 Requiring every virtual review to be face to face is considered unsustainable and impossible.
Verbatim wording from the response “Additionally, most reviews are expected to be done face to face, however, it is also accepted that a colleague may ask for advice without face-to-face review and there are professional standards around this. There are multiple situations where a virtual review is acceptable, and it would be unsustainable and impossible for every review to be done face to face. This would be the same process between all health care professionals.” Source location Response from Lewisham and Greenwich NHS Trust
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29 Jan 2025 Naomi SULEYMAN · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 9 Failure to make accurate referrals to the District Nursing team View source Failure of communication between D2A therapists and District Nurses View source Failure to complete accurate discharge passports containing patients’ clinical, therapy, equipment and home-environment needs View source Failure to provide social work and/or occupational therapy assessment within 24 hours of discharge View source Lack of capacity in the in-house Enablement team View source Failure to conduct an overarching coordinated investigation of the integrated multidisciplinary discharge process View source Delays in District Nursing assessment after referral View source Failure to provide an out-of-hours social worker welfare check on the day of discharge View source Failure to identify deficient discharge passports during Hospital Flow Centre screening View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Naomi SULEYMAN · 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
Naomi Suleyman developed and later died from pneumonia and complications of an unstageable sacral pressure sore after discharge from hospital, during a period when she was deconditioned and bedbound while her long-term needs were assessed. Concerns included inaccurate discharge information, missed welfare and therapy visits, an incorrect district nursing referral, poor communication between services, and missed opportunities to recognise and address that her discharge was unsafe.
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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make accurate referrals to the District Nursing team
Wider context from the report “(1) The referral to the District Nursing team was incorrect in that it wrongly referred to Mrs Suleyman having a sacral DTI on discharge . This led the District Nursing team to believe that she was already on the caseload of the community TVN team. This resulted in a delay in her being assessed by them.
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between D2A therapists and District Nurses
Wider context from the report “(2) There was little communication between the therapists from the D2A team and the District Nurses .
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete accurate discharge passports containing patients’ clinical, therapy, equipment and home-environment needs
Wider context from the report “(1) The ‘discharge passport’ completed by the UHL in-patient team was inaccurate , failing to record Ms Suleyman’s vulnerability to pressure ulcers, the need for therapies input from day 1, the equipment she required and that her home environment had not been optimised to meet her needs both in terms of equipment and layout . Whilst I heard that scrutiny of the discharge passport had improved at ward level, deficient discharge passports were still filtering through to the D2A 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide social work and/or occupational therapy assessment within 24 hours of discharge
Wider context from the report “(4) Due to lack of capacity, Ms Suleyman’s interim care needs pending assessment were brokered to a care provider. As a result, she did not receive a visit from a social worker and/or occupational therapist within 24 hours of discharge as she would have done if her care needs had been provided by the in-house Enablement 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of capacity in the in-house Enablement team
Wider context from the report “(4) Due to lack of capacity , Ms Suleyman’s interim care needs pending assessment were brokered to a care provider. As a result, she did not receive a visit from a social worker and/or occupational therapist within 24 hours of discharge as she would have done if her care needs had been provided by the in-house Enablement 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct an overarching coordinated investigation of the integrated multidisciplinary discharge process
Wider context from the report “The issues relating to LBL only emerged in evidence during the inquest. LGT in-patient and District Nursing services have taken some steps towards addressing their deficiencies. However, there has been a fragmented and incomplete response . There has been no overarching coordinated investigation involving all the key services relevant to what is intended to be an integrated multi-disciplinary discharge process .
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in District Nursing assessment after referral
Wider context from the report “(1) The referral to the District Nursing team was incorrect in that it wrongly referred to Mrs Suleyman having a sacral DTI on discharge. This led the District Nursing team to believe that she was already on the caseload of the community TVN team. This resulted in a delay in her being assessed by them .
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an out-of-hours social worker welfare check on the day of discharge
Wider context from the report “(3) On the day of discharge, Ms Suleyman should have received a welfare check from the LBL out of hours social worker which did not happen .
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify deficient discharge passports during Hospital Flow Centre screening
Wider context from the report “(2) The deficiencies in the discharge passport were not identified when it was screened by the LGT Hospital Flow Centre .
” 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 Progress the Occupational Therapy Policy through Trust governance approval.
Verbatim wording from the response “• An Occupational Therapy Policy has been developed which outlines roles, responsibilities and processes relating to therapy practice for environmental assessments and equipment provision. This is currently being agreed through the Trusts governance procedures.” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
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 Deliver training for community therapy services and District Nurses on available services and referral procedures.
Verbatim wording from the response “• Additionally, training sessions will be initiated for community therapy services and district nurses and delivered between April and June 2025 to enhance awareness of available services and referral procedures.” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
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 Provide same-day Enablement Care Officer visits after discharge to assess care suitability and escalate changes.
Verbatim wording from the response “• Any client in receipt of Enablement or brokered out care provision now receives a visit from an Enablement Care Officer, this visit happens the same day that the patient is discharged from hospital and reviews the suitability of care provision once the patient is in their own environment. Any changes are fed back to the Discharge to Assess Team (occupational therapist, physiotherapist or social worker) and patient, carer or other family members.” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
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 Strengthen multidisciplinary discharge-passport completion, checking, approval, electronic-record updating and daily validation before discharge.
Verbatim wording from the response “• Each member of the ward-based team, who is involved in the patient care, now provides input into the centrally located (and saved) discharge passports.” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
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 Establish and disseminate an escalation and information-sharing pathway across community services, with ongoing monitoring and audit.
Verbatim wording from the response “• There is now an established pathway, for escalation of concerns and information sharing between community services (Podiatry, District nursing and Community therapies/Enablement). This information has been shared across the services and embedded at all levels and will be monitored and audited moving forward.” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
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 Provide next-day out-of-hours welfare calls by a therapist or social worker for patients discharged between 5pm and 8pm.
Verbatim wording from the response “• For those patients discharged out of hours between 5pm-8pm) the out of hours social worker ensures that a welfare call is carried out the next day by a therapist and/or social worker” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
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 Maintain regular Discharge to Assess–District Nursing meetings and a communication champion to oversee information exchange and care-plan adherence.
Verbatim wording from the response “• In response to the report highlighting limited communication between the Discharge to Assess team and District Nurses, regular meetings have already been established between the teams to ensure consistent exchange of patient information. A staff member, or communication champion, has been appointed to oversee this process and ensure that care plans are followed. These communication efforts are being actively monitored and evaluated to confirm their effectiveness in preventing any future issues.” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
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 Conduct further multi-agency discharge events to improve communication and joint working.
Verbatim wording from the response “• A multi-agency discharge event was carried out on 05/03/2025 which tests the systematic approach to discharge processes and further events are planned to improve multi agency communication and ways of working.” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
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 Develop standards, role definitions, guidance and staff teaching for prescribing pressure-care equipment and hospital beds.
Verbatim wording from the response “• A multidisciplinary task and finish group has commenced work to outline standards of practice, and to define roles and responsibilities relating to prescription of pressure care equipment and hospital beds. The project will be undertaken using Quality improvement methodology and will produce guidance materials and teaching for staff by end of April 2025.” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
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 Perform additional electronic-record checks for last-minute changes in condition or discharge support needs under an embedded discharge protocol.
Verbatim wording from the response “• The discharge team now perform additional checks on the patient electronic care record to ensure there have been no last-minute changes in the patient's condition or discharge support needs. This is underpinned by a new protocol which has been shared with the team and operationally embedded into working practices.” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
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 The District Nursing referral was timely and correctly recorded both the foot ulcers and sacral ulcer, contrary to the concern.
Verbatim wording from the response “• On further investigation the District Nursing referral was done in a timely way from the ward on the day of discharge and received and actioned by the DN team. The referral noted both the foot ulcers and the sacral ulcer correctly.” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
Open published response
13 Jul 2021 Abiodun Adisa ORITOGUN · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Inadequate care planning for monitoring and observations after clinical deterioration View source Failure to ensure adequate monitoring and observations for patients with severe pancreatitis View source Failure to ensure that ITU admission criteria are not driven by capacity constraints View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Abiodun Adisa ORITOGUN · 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
Mr Abiodun Adisa Oritogun was admitted with severe acute pancreatitis, deteriorated on the ward, and died after collapsing while self-discharging; the inquest concluded that he died from complications of pancreatitis and ileus. Concerns included inadequate monitoring and escalation after his condition worsened, and uncertainty about whether patients with severe pancreatitis received an appropriate level of care and ITU referral.
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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate care planning for monitoring and observations after clinical deterioration
Wider context from the report “The coroner found that there were two concerns about medical care, namely
1. He was considered to be in alcohol withdrawal, (which evidence was not concluded either way) but there was an inadequate care plan with regard to monitoring and observations following his MEWS score rising from 1 to 10 and having a peri-arrest , which should have triggered formal ITU referral (he was seen by outreach nurses) and should have led to finding a cause of his deterioration and subsequent agitation and implemented closer monitoring . The reviewing doctor has reflected and embraced learning.
2. The consultant surgeon gave evidence that Mr Oritogun had a significant risk of arrhythmia related to electrolyte disturbances, although the evidence admitted was that these had been corrected prior to death. She nevertheless concluded that he died of a cardiac arrhythmia, which was not accepted as proven by the court, although it remained a possible cause. She opined that all cases of severe pancreatitis should be cared for in ITU, as they were at risk of sudden death, and they needed a degree of monitoring and observation not available on the general ward. She regretted that she had to accept the decisions of the ITU and informed the court that there may be preventable deaths that occur from not being given care in ITU. She gave evidence that other hospitals had a policy of admitting severe pancreatitis to ITU. Only when evidence of the Trust ITU consultant was admitted, suggesting that requirement of organ failure support was usually needed for admission. The surgeon’s testimony was given despite the Trust embarking on discussions between ITU and General surgery about the matter over the past year.
Whilst the Trust has an Action Plan to consider these matters, it has not been fully implemented a year after death and it is not clear that
a) it will ensure that patients with severe pancreatitis secure adequate monitoring and observations, whether in ITU, HDU or the ward
b) in determining the appropriate criteria for admission to ITU, that they will not be driven by ITU capacity constraints if it is clinically inappropriate to provide a lower level of care.
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure adequate monitoring and observations for patients with severe pancreatitis
Wider context from the report “The coroner found that there were two concerns about medical care, namely
1. He was considered to be in alcohol withdrawal, (which evidence was not concluded either way) but there was an inadequate care plan with regard to monitoring and observations following his MEWS score rising from 1 to 10 and having a peri-arrest, which should have triggered formal ITU referral (he was seen by outreach nurses) and should have led to finding a cause of his deterioration and subsequent agitation and implemented closer monitoring. The reviewing doctor has reflected and embraced learning.
2. The consultant surgeon gave evidence that Mr Oritogun had a significant risk of arrhythmia related to electrolyte disturbances, although the evidence admitted was that these had been corrected prior to death. She nevertheless concluded that he died of a cardiac arrhythmia, which was not accepted as proven by the court, although it remained a possible cause. She opined that all cases of severe pancreatitis should be cared for in ITU , as they were at risk of sudden death, and they needed a degree of monitoring and observation not available on the general ward . She regretted that she had to accept the decisions of the ITU and informed the court that there may be preventable deaths that occur from not being given care in ITU. She gave evidence that other hospitals had a policy of admitting severe pancreatitis to ITU. Only when evidence of the Trust ITU consultant was admitted, suggesting that requirement of organ failure support was usually needed for admission. The surgeon’s testimony was given despite the Trust embarking on discussions between ITU and General surgery about the matter over the past year.
Whilst the Trust has an Action Plan to consider these matters, it has not been fully implemented a year after death and it is not clear that
a) it will ensure that patients with severe pancreatitis secure adequate monitoring and observations, whether in ITU, HDU or the ward
b) in determining the appropriate criteria for admission to ITU, that they will not be driven by ITU capacity constraints if it is clinically inappropriate to provide a lower level of care.
” 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that ITU admission criteria are not driven by capacity constraints
Wider context from the report “The coroner found that there were two concerns about medical care, namely
1. He was considered to be in alcohol withdrawal, (which evidence was not concluded either way) but there was an inadequate care plan with regard to monitoring and observations following his MEWS score rising from 1 to 10 and having a peri-arrest, which should have triggered formal ITU referral (he was seen by outreach nurses) and should have led to finding a cause of his deterioration and subsequent agitation and implemented closer monitoring. The reviewing doctor has reflected and embraced learning.
2. The consultant surgeon gave evidence that Mr Oritogun had a significant risk of arrhythmia related to electrolyte disturbances, although the evidence admitted was that these had been corrected prior to death. She nevertheless concluded that he died of a cardiac arrhythmia, which was not accepted as proven by the court, although it remained a possible cause. She opined that all cases of severe pancreatitis should be cared for in ITU, as they were at risk of sudden death, and they needed a degree of monitoring and observation not available on the general ward. She regretted that she had to accept the decisions of the ITU and informed the court that there may be preventable deaths that occur from not being given care in ITU. She gave evidence that other hospitals had a policy of admitting severe pancreatitis to ITU. Only when evidence of the Trust ITU consultant was admitted, suggesting that requirement of organ failure support was usually needed for admission. The surgeon’s testimony was given despite the Trust embarking on discussions between ITU and General surgery about the matter over the past year.
Whilst the Trust has an Action Plan to consider these matters, it has not been fully implemented a year after death and it is not clear that
a) it will ensure that patients with severe pancreatitis secure adequate monitoring and observations, whether in ITU, HDU or the ward
b) in determining the appropriate criteria for admission to ITU, that they will not be driven by ITU capacity constraints if it is clinically inappropriate to provide a lower level of 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 Provide immediate critical-care doctor and outreach-nurse support, continuous trained staffing in the safest available area, and transfer to critical care when a bed becomes available.
Verbatim wording from the response “In the immediate response, we provide a critical care doctor (or airway trained anaesthetist) and a CCOT nurse to care for such patients wherever they may be, whether in the general wards, operating theatres, emergency department or elsewhere in the hospital.” Source location Response from Lewisham and Greenwich NHS
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 Apply nationally derived critical-care admission criteria, with urgent intensive-care review within 60 minutes and admission or ward-management advice.
Verbatim wording from the response “Our criteria for admission to critical care (ITU or HDU) are the same as those adopted nationally. These criteria are derived from “Guidelines on admission to and discharge from Intensive Care and High Dependency Units” published by the Department of Health in March 1996; these guidelines are still applicable and current. The type of patients who require ITU care are unstable and have a requirement for multiple organ monitoring and/or support. Patients admitted to HDU are those requiring single organ support, or those who need observation and monitoring that cannot be safely provided on a general ward.” Source location Response from Lewisham and Greenwich NHS
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 Provide enhanced nursing observation through the 24-hour Critical Care Outreach Team for patients managed outside critical care.
Verbatim wording from the response “Although Mr Oritogun was not referred to critical care for subsequent deterioration in his NEWS score, it is unlikely that his management would have changed through admission to ITU or HDU in the absence of organ failure. His nursing observation was enhanced through the provision of regular reviews by the Critical Care Outreach team (CCOT).” Source location Response from Lewisham and Greenwich NHS
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 Use the SELACCN and SPRINT support agreement to facilitate transfer to the nearest available critical-care bed when local capacity is unavailable.
Verbatim wording from the response “As a secondary response, where an urgent bed is unlikely to become available within our own hospital critical care unit, we have a support agreement in place with the South-East London Adult Critical Care Network (SELACCN) and the Specialist Retrieval and Intensive Care Transfer service (SPRINT). The SPRINT team includes a critical care consultant, nurse and paramedic who can provide ITU and HDU level care in an ambulance, and operates its base from our own NHS Trust.” Source location Response from Lewisham and Greenwich NHS
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 Patients not requiring critical care can receive adequate ward monitoring, cardiac monitoring where needed, and 24-hour enhanced nursing observation through CCOT.
Verbatim wording from the response “Where patients with severe pancreatitis require such observation, monitoring or organ support, they would need to be referred by their team of ward doctors or responsible consultant surgeon to the critical care team. This would result in an urgent review by an intensive care doctor (within no longer than 60 minutes) and either admission to critical care or advice on further management being provided on how to continue a patient’s care and treatment on the general ward.” Source location Response from Lewisham and Greenwich NHS
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 Critical-care capacity constraints are addressed through immediate specialist support, safe interim care, and transfer arrangements to available local critical-care beds.
Verbatim wording from the response “In the immediate response, we provide a critical care doctor (or airway trained anaesthetist) and a CCOT nurse to care for such patients wherever they may be, whether in the general wards, operating theatres, emergency department or elsewhere in the hospital.” Source location Response from Lewisham and Greenwich NHS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Admission decisions are not refused or driven by critical-care bed shortages when lower-level care is clinically inappropriate.
Verbatim wording from the response “Critical care beds in both ITU and HDU are a finite resource. There can be times when demand outstrips available capacity. This is recognised nationally, and each NHS Trust is required to have plans available to deal with such capacity constraints.” Source location Response from Lewisham and Greenwich NHS
Open published response
29 May 2020 Master Omarian Brooks · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Dispute over hospital destination during ambulance transfer View source Failure to inform the GP of patient deterioration 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
Master Omarian Brooks · 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
Omarian Brooks, a severely disabled boy, deteriorated after being given antibiotics by his parents and died en route to hospital on 27 May, without having had a GP visit. Concerns included the GP apparently being unaware of his deterioration, the absence of a protocol for managing it, and the lack of a patient-specific emergency care protocol. The report states that earlier GP awareness might have led to hospital admission with a real prospect of successfully treating the infection.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Dispute over hospital destination during ambulance transfer
Wider context from the report “2. There was also a distressing dispute between the ambulance crew and parents as to which hospital Omarian should be taken , in the event he was not taken to the nearest hospital at the insistence of his parents (although in this instance the delay was not found to have contributed to the death).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the GP of patient deterioration
Wider context from the report “1. The Record concludes that had the GP been informed of the boy’s deterioration either 4 days before the antibiotic was started or soon after , he would have been admitted to hospital with a real prospect of the infection being successfully treated.
” Open source report
5 Mar 2015 Archie Haxell · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Failure to communicate possible signs of respiratory distress between midwives View source Failure to retain recorded observations in the medical records View source Failure to inform parents of concerns about their child’s breathing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Archie Haxell · 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
Archie Haxell was born by forceps delivery on 24 March 2013 and suffered a respiratory arrest about two hours after birth. He was transferred to St Thomas’ Hospital, where he died on 29 March 2013. The principal concerns were breakdowns in communication between healthcare professionals, failure to retain observation records, and failure to inform Archie’s parents about concerns regarding his breathing, contributing to delay in recognising his deteriorating condition.
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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate possible signs of respiratory distress between midwives
Wider context from the report “(1) About 25 minutes after his birth Archie was noted to be grunting and he then developed nasal flaring, both of which are potential signs of respiratory distress. He was ████████ performed a set of observations, including oxygen saturations and she also noticed vomiting, grunting and nasal flaring. The evidence at the inquest was that the observations on a piece of paper because the medical records were not immediately available (her observations were performed shortly after the birth of Archie’s brother who required resuscitation). Midwife ████████ later transcribed these results into the medical records. However, the evidence was that midwife ████████ was not aware of the vomiting, grunting and nasal flaring noticed by midwife ████████ although midwife ████████ believes she did pass this information on verbally.
During this period may understandably have been focussed on Archie’s brother. However, I am concerned that the important information about further possible signs of respiratory distress was somehow lost in the communication between the two midwives.
Also, the piece of paper on which the observations were recorded was not retained. I am concerned that this should have been retained in the 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain recorded observations in the medical records
Wider context from the report “(1) About 25 minutes after his birth Archie was noted to be grunting and he then developed nasal flaring, both of which are potential signs of respiratory distress. He was ████████ performed a set of observations, including oxygen saturations and she also noticed vomiting, grunting and nasal flaring. The evidence at the inquest was that the observations on a piece of paper because the medical records were not immediately available (her observations were performed shortly after the birth of Archie’s brother who required resuscitation). Midwife ████████ later transcribed these results into the medical records. However, the evidence was that midwife ████████ was not aware of the vomiting, grunting and nasal flaring noticed by midwife ████████ although midwife ████████ believes she did pass this information on verbally.
During this period may understandably have been focussed on Archie’s brother. However, I am concerned that the important information about further possible signs of respiratory distress was somehow lost in the communication between the two midwives.
Also, the piece of paper on which the observations were recorded was not retained . I am concerned that this should have been retained in the 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 Lewisham and Greenwich NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform parents of concerns about their child’s breathing
Wider context from the report “(2) No-one informed Archie’s parents of the concerns about Archie’s breathing. After returning to delivery suite ████████ was left alone with Archie for a period of between 7 and 10 minutes. During this period ████████ noted that Archie’s breathing was irregular. My finding at the inquest was that if he had known of the midwives’ concerns he would have raised the alarm sooner, although it was not possible to say from the evidence whether this would have altered the outcome.
I do of course understand that a balance needs to be maintained between sharing relevant information with parents and causing unnecessary alarm. However sharing relevant information potentially enables parents to make important contributions to their child’s care and my concern is that this opportunity was lost in this case .
” 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 Embed SBAR communication and escalation across the maternity service and monitor progress through quarterly Quality and Safety Committee updates.
Verbatim wording from the response “SBAR
Work is currently underway to embed the use of this communication tool (Situation, Background, Assessment, Recommendation) within the maternity service. This is a simple tool used by many NHS organisations to ensure that communication between healthcare professionals is clear and concise, and to support effective escalation of situations when necessary.” Source location 2015-0081-Response-by-Lewisham-Greenwich-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 Require staff to secure all loose clinical documentation in the main clinical notes.
Verbatim wording from the response “1 – Documentation
This issue was raised by the PFD report in relation to loose paper being used to document observations contemporaneously and later transcribed into the clinical notes. In this case the observations taken from Archie were transcribed into the clinical notes by a different person to the member of staff who had performed the observations. All members of staff have been reminded that any loose documentation must be secured into the main clinical notes even if written on a small piece of paper.” Source location 2015-0081-Response-by-Lewisham-Greenwich-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 Participate in the national Sign Up to Safety campaign through a Trust-wide initiative to reduce avoidable harm from failure to identify and act on deteriorating patients.
Verbatim wording from the response “This technique is already underway in the Children’s Division, the Maternity Service, and has been incorporated into a wider Trust initiative under the umbrella of the national Sign Up To Safety campaign and our pledge to reduce harm to the ‘deteriorating patient’. Progress will be monitored at the Trust’s Quality and Safety Committee where quarterly updates will be presented by the pledge leads. This committee is chaired by the Trust’s Deputy Medical Director for Quality and Safety.” Source location 2015-0081-Response-by-Lewisham-Greenwich-NHS-Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations