4 Mar 2022 Sarah-Louise Jennifer Doyle · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 2 Failure to conduct five-minute observations at frequent but unpredictable times View source Inadequate recording of individual five-minute observations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sarah-Louise Jennifer Doyle · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sarah-Louise Jennifer Doyle, aged 19, was found hanging in her room while detained under the Mental Health Act and subject to five-minute observations. She was taken to hospital but died at 01:40 on 27 February 2022; concerns were raised that observations were recorded at predictable times and may not have been precise.
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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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct five-minute observations at frequent but unpredictable times
Wider context from the report “On a review of the five minute observations these were recorded exactly on each five minutes after the hour – 05, 10, 15, 20 etc. It will be a matter for evidence to be heard at the inquest whether these times were precise or whether they were written in anticipation of future observations . The observations were covered by one signature with a downward arrow. In other settings it is better practice for five minute observations to be 12 frequent but unpredictable observations within each hour – to minimise the risk of a self-harm attempt being planned from the timing of previous observations .
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording of individual five-minute observations
Wider context from the report “On a review of the five minute observations these were recorded exactly on each five minutes after the hour – 05, 10, 15, 20 etc. It will be a matter for evidence to be heard at the inquest whether these times were precise or whether they were written in anticipation of future observations . The observations were covered by one signature with a downward arrow. In other settings it is better practice for five minute observations to be 12 frequent but unpredictable observations within each hour – to minimise the risk of a self-harm attempt being planned from the timing of previous observations.
” 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 Conduct local audits, spot checks and additional dip audits to verify accurate, random-time recording of supportive observations.
Verbatim wording from the response “4. A local audit has been developed with Inpatient Matrons to check and provide assurance that recording the actual time service users were checked is taking place, as opposed to rounding to the nearest 5-minute time window. As additional assurance, spot checks are being undertaken by the Senior Leadership Team and Inpatient Matron/Ward Manager group.” Source location 2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
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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 Standardize language and roll out recording observations at unpredictable times within five-, ten- or fifteen-minute windows.
Verbatim wording from the response “2. On March the 8th 2022 the Regulation 28 was discussed at the local division safety huddle with all inpatient Matrons present. An immediate action was for them to discuss with their” Source location 2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
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 Issue urgent instructions on using and recording intermittent supportive observations.
Verbatim wording from the response “I can confirm that in relation to supportive observations the following actions are already either complete or well underway:” Source location 2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
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 Introduce an electronic system supporting unpredictable-interval supportive observations.
Verbatim wording from the response “9. The Trust has reviewed the existing Ward Assurance Audit in relation to supportive observations. An interim change to recording has been made ahead of a scheduled electronic system going live in May 2022 which will reflect the need for supportive observations to be at unpredictable intervals. These audits are taking place weekly, and the highlights are shared in safety huddles and at divisional clinical meetings.” Source location 2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
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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 Complete annual supportive-observation competency assessments and observed practice checks for inpatient staff across Clock View and other Local Division wards.
Verbatim wording from the response “6. Inpatient staff are required to have yearly competence assessments regarding supportive observations. All of the staff on the wards in Clock View will have had their yearly competency updated on the supportive observation policy and will have been observed in practice carrying out at least 2 supportive observations checks by the end of April 2022. All of the other wards across Local Division will be completed by the end of May 2022.” Source location 2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
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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 Revise the Ward Assurance Audit, operate interim recording changes and conduct weekly audits with findings shared through safety and clinical meetings.
Verbatim wording from the response “9. The Trust has reviewed the existing Ward Assurance Audit in relation to supportive observations. An interim change to recording has been made ahead of a scheduled electronic system going live in May 2022 which will reflect the need for supportive observations to be at unpredictable intervals. These audits are taking place weekly, and the highlights are shared in safety huddles and at divisional clinical meetings.” Source location 2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
Open published response
Concerns raised 2 Failure of interagency working and sharing of key information View source Failure to make contemporaneous records and document decision-making rationale including capacity assessments 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
Danny James Holt-Scarpens · 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
Danny James Holt-Scarpens was found dead at home on 10 October 2019 after using a rope as a ligature to hang himself, having left goodbye notes. The concerns raised included inadequate interagency information sharing and the failure to make contemporaneous records or document decision-making, including the capacity assessment, during a crisis team telephone assessment.
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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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of interagency working and sharing of key information
Wider context from the report “i. There should be better interagency working and sharing of key information between agencies who had contact with the deceased in the period leading up to his 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make contemporaneous records and document decision-making rationale including capacity assessments
Wider context from the report “ii. The assessing crisis team clinician who undertook the telephone assessment with the deceased on the 30th July 2019, did not make contemporaneous records or document any decision-making rationale including detailing the capacity assessment undertaken .
” Open source report
Concerns raised 5 Failure of investigation staff to correctly understand and apply the observation policy View source Delays of up to 24 hours in recording clinical information View source Failure of ward management to understand the observation policy View source Failure to carry out patient observations at irregular intervals within the permitted time window View source Failure of ward supervision to check compliance with the observation policy View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Lauren Victoria Finch · 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
Lauren Victoria Finch, aged 23, died on 24 September 2018 after suspending herself from a bedroom door while detained as a patient at Atherleigh Park Hospital; she suffered a significant brain injury and later died in hospital. The principal concerns included inadequate suicide-risk assessment and review, inappropriate observation levels and practices, failures in the anti-barricade system, and delayed clinical record entries.
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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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of investigation staff to correctly understand and apply the observation policy
Wider context from the report “3. The Trust carried out an investigation following the death of Lauren. It was of concern that the lead investigator (who gave evidence at the inquest) did not understand the Observation Policy and suggested that observations should be carried out at irregular intervals (which was correct) but then gave an example of 10 minute observations being carried out at: 10 am, 10.08 am, 10.20 am (which is clearly not in accordance with the Policy) . The interval should never exceed the 10 minute period (and there is 12 minutes between 10.08 am and 10.20 am).
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays of up to 24 hours in recording clinical information
Wider context from the report “4. There were examples in the records of nursing staff putting in entries 24 hours after the event had occurred . Whilst it is accepted that nursing staff may, on occasion, need to wait some time before marking an entry into the clinical record, a period of 24 hours when dealing with patients at risk of self-harm and suicide means that relevant information is potentially not available to staff on the next shift .
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ward management to understand the observation policy
Wider context from the report “2. The Deputy Ward Manager on Westleigh Ward at Atherleigh Park Hospital confirmed that she did not and still does not check that observations by staff are being carried out in accordance with the Trust policy, despite accepting that this was her role when the nurse in charge of a shift. Further, the Deputy Manager of Westleigh Ward did not understand the Policy and thought that observations were to be carried out at regular intervals (as referred to above).
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out patient observations at irregular intervals within the permitted time window
Wider context from the report “1. Nursing staff and Health Care Assistants on Westleigh Ward at Atherleigh Park Hospital were carrying out (and continue to carry out) observations of patients at precise intervals (for example, if a patient is on half-hourly observations, staff explained that they would aim to carry out observations at 10.00 am, 10.30 a.m., 11 am etc.). Further, all records showed that the timings of observations were at precise intervals . This is not in accordance with the Trust’s policy of observations (which confirms that observations should be irregular but within the (e.g. 30 minute) window . The reason for this policy is clearly to avoid a situation whereby a patient can predict when they will next be observed (and offer an opportunity for the patient to take action to harm herself during that period of time).
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ward supervision to check compliance with the observation policy
Wider context from the report “2. The Deputy Ward Manager on Westleigh Ward at Atherleigh Park Hospital confirmed that she did not and still does not check that observations by staff are being carried out in accordance with the Trust policy , despite accepting that this was her role when the nurse in charge of a shift . Further, the Deputy Manager of Westleigh Ward did not understand the Policy and thought that observations were to be carried out at regular intervals (as referred to above).
” Open source report
Concerns raised 1 Lack of connectivity 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
Sharon Ann Halliwell · 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
Sharon Ann Halliwell was found deceased at home on 18 April 2017; the medical cause of death was suspension by ligature and the inquest concluded suicide. The report identified a lack of connectivity between mental health service systems, meaning information indicating suicide risk was not accessed during a later assessment and a psychiatrist referral was not made.
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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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of connectivity
Wider context from the report “Whilst other issues addressed in evidence had been addressed by the Trust the issue of lack of connectivity as described had not been fully addressed .
” Open source report
16 Jun 2017 Lee Joseph Hastings Swain · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2 Failure to ensure effective information exchange during mental health service transfers View source Failure to provide coordinated direct referrals and continuity of care during mental health service transfers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Lee Joseph Hastings Swain · 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
Lee Joseph Hastings-Swain, aged 28, was found deceased hanging from a bannister at his home on 30 November 2016. The inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included inadequate coordination and information-sharing between mental health services, delays in referral, poor clinical records, and insufficiently proactive engagement after his transfer between NHS trusts.
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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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure effective information exchange during mental health service transfers
Wider context from the report “A more co-ordinated approach from the mental health services is required when a user is being transferred from one NHS Trust to another. In this case if the user had still been on a Care Programme Approach there would have been a direct referral from service to service rather than through the GP but because he was taken off the programme the referral was made through the GP. This has delayed the intervention and the prevented effective information exchange on a user who was already subject to secondary care services . In effect this resulted in the user having no intervention for a number of months and entering the mental health system afresh when in fact the care should have been a seamless continuation.
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide coordinated direct referrals and continuity of care during mental health service transfers
Wider context from the report “A more co-ordinated approach from the mental health services is required when a user is being transferred from one NHS Trust to another. In this case if the user had still been on a Care Programme Approach there would have been a direct referral from service to service rather than through the GP but because he was taken off the programme the referral was made through the GP . This has delayed the intervention and the prevented effective information exchange on a user who was already subject to secondary care services. In effect this resulted in the user having no intervention for a number of months and entering the mental health system afresh when in fact the care should have been a seamless continuation .
” 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 Amend the transfer policy to require timely, comprehensive handover of information for CPA and non-CPA service users.
Verbatim wording from the response “Mersey Care NHS Foundation Trust (MCFT) response
I have enclosed the key changes that have been made to policy following the Regulation 28 report at Appendix 1.” Source location 2017-0196-Mersey-Care-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider including an audit of transfer processes in the Junior Doctor Audit programme.
Verbatim wording from the response “An audit of transfer processes based on the amended policies will be considered for inclusion in each Trust’s Junior Doctor Audit programme.” Source location 2017-0196-Mersey-Care-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate the inquest outcome and transfer-policy changes through operational management meetings, consultant forums and a Quality Practice Alert.
Verbatim wording from the response “I can confirm that the outcome of the inquest hearing and the required changes to the policy have been circulated within MCFT through operational management meetings, consultant forums and via Quality Practice Alert (QPA). I can also confirm that the QPA was issued prior to the Inquest hearing on 16th March 2017 as part of the Trust’s processes of learning from this incident. This included clear guidance on what is expected of teams when a patient is being transferred from one organisation to another. The contents of the QPA included:-” Source location 2017-0196-Mersey-Care-NHS-Trust
Open published response
Concerns raised 2 Failure to distinguish inability to consent from refusal of x-ray View source Failure to take physiological readings when assessing physiological response to fracture 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
Joan RIMMER · 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
Joan Rimmer, who had dementia and lived in a residential home, suffered an unwitnessed fall on 28 November 2016 and was later diagnosed with a right hip fracture. She underwent surgery but subsequently stopped eating and drinking and died on 16 January 2017. The court was concerned that the community matron assessed her without taking physiological readings and wrongly judged that she had refused an X-ray, contributing in part to a two-week delay in diagnosing the fracture.
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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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to distinguish inability to consent from refusal of x-ray
Wider context from the report “Though there was no evidence that Mrs Rimmer’s death could have been avoided by earlier diagnosis of her fractured hip – the court is concerned that the Community Matron employed by Liverpool Community Health assessed her physiological response to a fracture without taking any physiological readings and further adjudged her to refuse to be x-rayed when a carer witness who was present has explained that the extent of her dementia on the 29th November was so severe she would not understand sufficient to give consent . This in part led to a two week delay before her hip fracture was diagnosed. In another case such standards of nursing could result in an avoidable death not being prevented.
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to take physiological readings when assessing physiological response to fracture
Wider context from the report “Though there was no evidence that Mrs Rimmer’s death could have been avoided by earlier diagnosis of her fractured hip – the court is concerned that the Community Matron employed by Liverpool Community Health assessed her physiological response to a fracture without taking any physiological readings and further adjudged her to refuse to be x-rayed when a carer witness who was present has explained that the extent of her dementia on the 29th November was so severe she would not understand sufficient to give consent. This in part led to a two week delay before her hip fracture was diagnosed. In another case such standards of nursing could result in an avoidable death not being prevented.
” Open source report
Concerns raised 3 Ineffective communication between administrative staff and nursing or clinical staff View source Lack of a default to urgent referral when screening is not possible or referral information is doubtful or ambiguous View source Imprecise guidance for categorising referral urgency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
David Moran · 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
David Moran, who had bipolar affective disorder and a history including suicide attempt and suicidal ideation, died after taking a fatal overdose of metformin; the inquest could not determine his intention. Concerns included imprecise referral-priority guidance, the absence of a default urgent response when screening was not possible or the situation was ambiguous, and ineffective communication between administrative and clinical staff.
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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective communication between administrative staff and nursing or clinical staff
Wider context from the report “(2) Communication between administrative staff and nursing / clinical staff did not appear to be effective.
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a default to urgent referral when screening is not possible or referral information is doubtful or ambiguous
Wider context from the report “(1) The Trust Guidance for categorising the urgency of a referral appeared imprecise. Further, in that the referral system will often depend on a telephone conversation only, there did not appear to be a default to urgent in a case where a screening assessment was not possible or in a case of doubt or ambiguity .
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Imprecise guidance for categorising referral urgency
Wider context from the report “(1) The Trust Guidance for categorising the urgency of a referral appeared imprecise. Further, in that the referral system will often depend on a telephone conversation only, there did not appear to be a default to urgent in a case where a screening assessment was not possible or in a case of doubt or ambiguity.
” Open source report
Concerns raised 2 Failure to process and action referrals to the community mental health team View source Failure by support services to act on and follow up service-user overdose disclosures View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lee Francis Grimes · 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
Lee Francis Grimes, who was known to misuse cocaine and had schizophrenia, was found collapsed and unresponsive at home on 21 March 2016. Before his death, he disclosed on two occasions that he had taken an overdose of prescribed medication, but the disclosures did not result in assessment or treatment, and a message to the Community Mental Health Team was not followed up or acted upon. The report raised concerns about failures in responding to overdose disclosures and referral messages, and about staff training and procedures.
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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to process and action referrals to the community mental health team
Wider context from the report “i. That no action was taken by an employee of Next Stage following Mr Grimes’ disclosure of an overdose of medication on Thursday the 17th March. I have further concern that when action was taken on the Friday 18th March, a message was left for the Community Mental Health Team which was not followed up by Next Stage, or answered and actioned by the Community Mental Health Team . Although Mr Grimes’ death was not as a result of an overdose, he did not receive any assessment, or treatment, in respect of the overdose he disclosed. In view of the fact that there was no contact from the Next Stage or the Community Mental Health team over the weekend, he was vulnerable to taking a further overdose of medication.
ii. I have concerns that if this situation occurs in the future, another person could die. In view of that I would ask that the current policies and procedures in place at Next Stage to deal with the disclosure of an overdose of medication by a service user, are reviewed, and cascaded down to all employees. I would also request that a review is carried out by 5 Boroughs Partnership of the policies and procedures in place regarding the processing of referrals to Wigan Recovery North given the fact that the message left by ████████ on the Friday morning was never acted upon , as if this were to happen again in the future I believe there could be a further 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by support services to act on and follow up service-user overdose disclosures
Wider context from the report “i. That no action was taken by an employee of Next Stage following Mr Grimes’ disclosure of an overdose of medication on Thursday the 17th March. I have further concern that when action was taken on the Friday 18th March, a message was left for the Community Mental Health Team which was not followed up by Next Stage , or answered and actioned by the Community Mental Health Team. Although Mr Grimes’ death was not as a result of an overdose, he did not receive any assessment, or treatment, in respect of the overdose he disclosed . In view of the fact that there was no contact from the Next Stage or the Community Mental Health team over the weekend, he was vulnerable to taking a further overdose of medication.
ii. I have concerns that if this situation occurs in the future, another person could die. In view of that I would ask that the current policies and procedures in place at Next Stage to deal with the disclosure of an overdose of medication by a service user , are reviewed, and cascaded down to all employees. I would also request that a review is carried out by 5 Boroughs Partnership of the policies and procedures in place regarding the processing of referrals to Wigan Recovery North given the fact that the message left by ████████ on the Friday morning was never acted upon, as if this were to happen again in the future I believe there could be a further death.
” Open source report
Concerns raised 1 Lack of guidance for managing refusal of physical health observations and escalating for medical assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Clarice Beverley Hilton · 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
Clarice Beverley Hilton, who had depression and anxiety, was admitted to a psychiatric unit after refusing food, fluids and prescribed medication. She refused physical observations after the first evening, became unresponsive following a deterioration in her physical health, and died on 23 January 2016 after transfer to hospital. The principal concern was the absence of policy or guidance for monitoring and responding when psychiatric patients refuse physical observations and MEWS assessment.
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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for managing refusal of physical health observations and escalating for medical assessment
Wider context from the report “i. That there is no policy or guidance in place within the psychiatric units governed by 5 Boroughs Partnership NHS Foundation Trust as to what action to take when a patient is refusing to allow the nursing staff to undertake observations to establish the condition of their physical health . I therefore request that consideration be given to establishing a policy within the Trust for the monitoring of the physical health of patients within the psychiatric unit in circumstances where a patient refuses to allow the nursing staff to calculate their MEWS, which would provide guidance to the nursing staff as to what action should be taken in these circumstances and when it is appropriate for a referral to be made for a Doctor to assess whether a patient requires transfer to the Medical Assessment Unit for further assessment and treatment .
” Open source report
Concerns raised 8 Failure to record advice on medical treatment and care View source Failure of Lakeside Unit clinical notes to identify actions, times and clinicians View source Lack of triage procedures for urgent or unexpected significant x-ray findings View source Failure of Lakeside Unit clinicians to understand x-ray request and urgency requirements View source Failure of 5BP and WWL to maintain a shared understanding and interpretation of the Service Agreement View source Unavailability of electronic access to WWL x-rays for 5BP clinicians View source Unavailability of physiotherapy and occupational therapy for Lakeside Unit patients View source Failure of nominated officers to review the operation and performance of Service Agreements 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.
×
AI-generated summary
Harry Pryal · 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
Harry Pryal died on 8 January 2015 after an accidental fall, with the inquest recording bronchopneumonia and traumatic spinal cord injury as the medical cause of death. An X-ray identifying a suspected cervical spine fracture was not reported promptly, and the report raised concerns about communication and record-keeping, conflicting interpretations of a radiology service agreement, access to imaging, and the provision of physical healthcare services.
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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record advice on medical treatment and care
Wider context from the report “i. 5BP contact WWL for advise in relation to medical treatment for patients at the Lakeside Unit on a regular basis as a matter of protocol. The Doctors in psychiatry at the Lakeside Unit, are dependent upon such advice for the treatment and care of patients.
The evidence identified that there is no note of the advice in the records maintained by WWL, neither to identify the Doctor giving advice nor the content of the advice . Furthermore evidence was given that this was a situation arising on a nationwide scale. The absence of any notes prevents a record of the advice for the purpose of continuity of treatment and any subsequent referrals , particularly in a case when the Doctor giving the advice is no longer available and further advice is requested by the referring Doctor for medical treatment.
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Lakeside Unit clinical notes to identify actions, times and clinicians
Wider context from the report “v. The evidence at the Inquest revealed that the notes completed by clinicians at the Lakeside Unit, failed to identify the times of actions by them and in one note failed to identify the identity of the clinician making the note . The notes were inadequate , particularly the notes which accompanied Mr Pryal on his transfer from the Lakeside Unit, to RAEI.
The details to be included in a request for x-ray examination and the fact that an urgent x-ray examination required either a telephone call to the Radiologist or a note of priority on the x-ray form did not appear to be understood by clinicians at the Lakeside Unit, and demonstrated a lack of liaison and understanding between the two Trusts, which would be necessary to allow the terms of the Service Agreement to be operated and performed.
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of triage procedures for urgent or unexpected significant x-ray findings
Wider context from the report “iii. The evidence given by WWL was that there were no time lines in relation to the reporting of x-ray performed at the Leigh Infirmary, other than national timelines , although it was accepted that the Service Agreement provided that “urgent or unexpected significant clinical findings will be communicated to referring clinicians at the time of the Consultant Radiological reporting”. It was accepted if there was an unexpected significant clinical finding it would be necessary to communicate the finding to the referring clinician without delay.
WWL do not have any triage procedures in relation to x-ray examinations so that any “urgent or unexpected significant clinical finding” would not be reported to the referring clinician for some time after the examination . An early triage of the x-ray examination within a short period of the examination would allow any urgent or unexpected significant clinical finding to be communicated to the referring clinician without delay.
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Lakeside Unit clinicians to understand x-ray request and urgency requirements
Wider context from the report “v. The evidence at the Inquest revealed that the notes completed by clinicians at the Lakeside Unit, failed to identify the times of actions by them and in one note failed to identify the identity of the clinician making the note. The notes were inadequate, particularly the notes which accompanied Mr Pryal on his transfer from the Lakeside Unit, to RAEI.
The details to be included in a request for x-ray examination and the fact that an urgent x-ray examination required either a telephone call to the Radiologist or a note of priority on the x-ray form did not appear to be understood by clinicians at the Lakeside Unit, and demonstrated a lack of liaison and understanding between the two Trusts, which would be necessary to allow the terms of the Service Agreement to be operated and performed.
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of 5BP and WWL to maintain a shared understanding and interpretation of the Service Agreement
Wider context from the report “ii. The Service Agreement entered into between 5BP and WWL for the period from the 1st April 2014 to the 31st March 2015 was the subject of different interpretations by each Trust. There was confusion in relation to the prioritisation of imaging and there was a fundamental conflict in relation to the interpretation of clause 2.1 .
The Agreement provided for meetings between nominated officers from each trust at intervals not exceeding every 3 months from the effective date of the Agreement to consider any issues arising from the operation and performance of the Agreement, as provided in paragraph 14.1 on page 10 of the Agreement. The evidence of the Inquest confirmed that no meetings had taken place during the concurrence of the Agreement and there was no proactive involvement of the nominated officers to identify any issues arising from the operation and performance of the Agreement. Furthermore evidence was given that there were similar Service Agreements for the period from 1st April 2013 to the 31st March 2014 and from the 1st April 2015 to the 31st March 2016 with similar provisions for meetings during the concurrence of the Agreements but no meetings between nominated officers had ever taken place.
The evidence identified a lack of liaison and understanding between 5BP and WWL in relation to the Agreement and their relationship , even in circumstances where both trusts are operating on the same site at Leigh Infirmary, Leigh.
During the Inquest WWL confirmed that they had similar Service Agreements in relation to the provision of services to health professionals in other areas of treatment and the provisions of all Agreements were similar and the provisions in all Agreements may not be performed in accordance with the requirements of each Agreement.
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of electronic access to WWL x-rays for 5BP clinicians
Wider context from the report “iv. 5BP accepted that the Service Agreement provided for web viewing of the x-rays but accepted that the software operated by 5BP does not allow web viewing of x-rays and 5BP did not have network connections to view the x-rays electronically by access to the WWL network . In any event the Consultant Psychiatrist from the Lakeside Unit indicated that the Doctors in her team based at the Lakeside Unit, may not have the expertise to interpret the x-rays on web view and the Doctors would be dependent upon a formal report, either verbal or written, from the Radiologist.
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of physiotherapy and occupational therapy for Lakeside Unit patients
Wider context from the report “vi. Evidence was given at the Inquest that there was no physiotherapy or occupational therapy at the Lakeside Unit to deal with the physical health needs of any patients on the Unit . There was no Service Agreement for the provision of physiotherapy and occupational therapy and no understanding as to who would provide such services . The evidence indicated that the Clinical Commissioning Group in Wigan would provide the services and 5BP were not in a position to enter into agreements for the provision of services from elsewhere. Evidence was given by 5BP that the Clinical Commissioning Group in Wigan had not provided services so that the physical health needs of patients in the Lakeside Unit, were not being satisfied in relation to physiotherapy and occupational therapy .
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nominated officers to review the operation and performance of Service Agreements
Wider context from the report “ii. The Service Agreement entered into between 5BP and WWL for the period from the 1st April 2014 to the 31st March 2015 was the subject of different interpretations by each Trust. There was confusion in relation to the prioritisation of imaging and there was a fundamental conflict in relation to the interpretation of clause 2.1.
The Agreement provided for meetings between nominated officers from each trust at intervals not exceeding every 3 months from the effective date of the Agreement to consider any issues arising from the operation and performance of the Agreement, as provided in paragraph 14.1 on page 10 of the Agreement. The evidence of the Inquest confirmed that no meetings had taken place during the concurrence of the Agreement and there was no proactive involvement of the nominated officers to identify any issues arising from the operation and performance of the Agreement . Furthermore evidence was given that there were similar Service Agreements for the period from 1st April 2013 to the 31st March 2014 and from the 1st April 2015 to the 31st March 2016 with similar provisions for meetings during the concurrence of the Agreements but no meetings between nominated officers had ever taken place .
The evidence identified a lack of liaison and understanding between 5BP and WWL in relation to the Agreement and their relationship, even in circumstances where both trusts are operating on the same site at Leigh Infirmary, Leigh.
During the Inquest WWL confirmed that they had similar Service Agreements in relation to the provision of services to health professionals in other areas of treatment and the provisions of all Agreements were similar and the provisions in all Agreements may not be performed in accordance with the requirements of each Agreement.
” Open source report
Concerns raised 4 Unavailability of inpatient psychological input due to uncovered staff absence View source Failure of the referral process to ensure timely and non-duplicative referral to outpatient psychological services View source Failure to communicate the full extent of family-reported suicide-related concerns to the Recovery Team View source Failure of the Recovery Team to attend discharge planning meetings View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Roseanne Cooke · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Roseanne Cooke experienced a marked deterioration in her mental health, including suicidal thoughts, and was found having taken her own life at her mother’s home on 1 May 2014. The report identified concerns about unavailable inpatient psychological input, confusion and delays regarding psychological-service referrals, the absence of the Recovery Team from a discharge-planning meeting, and inadequate communication of the family’s concerns about her safety.
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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of inpatient psychological input due to uncovered staff absence
Wider context from the report “It was clear from the evidence that the deceased required psychological input. The Inquest heard evidence that whilst she was an inpatient on the Grasmere Unit there was no inpatient psychological input available due to maternity leave which had not been covered .
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the referral process to ensure timely and non-duplicative referral to outpatient psychological services
Wider context from the report “There was confusion in the evidence as to whether, whilst an inpatient on Grasmere, a referral had been made to outpatient psychological services (i.e. the Recovery Team services). This resulted in a referral being made by her Care Co-ordinator on the 24th April when she had been already been discharged home. This confusion meant that there was either a delay in any referral being made or at best a duplication of her referral .
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the full extent of family-reported suicide-related concerns to the Recovery Team
Wider context from the report “On the 28th April, the deceased’s family contacted the Home Treatment Team out of hours numbers available to them as they had concerns about the deceased being in the house on her own the following day as she was having suicidal thoughts. Their understanding of the request was that someone from the Recovery Team would visit her the following day. The message passed to the Recovery Team was simply to make contact with the deceased, which was done over the phone. The extent of the concerns raised by the family was not communicated to the Recovery 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Recovery Team to attend discharge planning meetings
Wider context from the report “On the 17th April there was a meeting which ultimately led to the discharge of the deceased from hospital. The Care Co-Coordinator had already expressed that she would not be available due to annual leave but had left details of her colleague who would attend if this was a discharge planning meeting. No-one from the Recovery Team attended this meeting. They were the prime carers for the deceased on her discharge and had the role of Care Co-ordinator.
” Open source report
Concerns raised 3 Failure to respond promptly to failed visits caused by lack of access View source Absence of a partnership agreement between the fire service and mental health trust View source Failure to arrange appointments with vulnerable individuals in accordance with Health Professional directions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Magdalen Bernadette Dwerryhouse · 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
Magdalen Bernadette Dwerryhouse, who lived alone and was being assessed for a paranoid mental illness, died at home on 25 November 2013 after a kitchen fire; she was found collapsed and unresponsive at the bottom of the stairs. Concerns included the arrangements for appointments with vulnerable people, the response to a failed home visit and the lack of partnership working between the mental health trust and the fire service regarding fire-risk prevention.
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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to respond promptly to failed visits caused by lack of access
Wider context from the report “ii. I have further concerns with regard to procedures to be undertaken if a visit fails for lack of access including contact with family and the original referrer to rearrange an appointment as soon as possible .
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a partnership agreement between the fire service and mental health trust
Wider context from the report “iii. The absence of any partnership agreement between the Greater Manchester Fire Service and 5 Boroughs NHS Foundation Trust which has failed to develop over the last two years and which is essential to allow the Fire Service to take action to prevent future deaths .
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange appointments with vulnerable individuals in accordance with Health Professional directions
Wider context from the report “i. The systems and procedures within 5 Boroughs Partnership NHS Foundation Trust with regard to the arrangements of appointments with vulnerable individuals particularly when directions are given by a Health Professional , namely ████████ in the case of the deceased.
” Open source report
Concerns raised 8 Unavailability of the computerised referral list to Senior Nurse Practitioners View source Failure of handover and review systems to manage failed-contact referrals View source Insufficient staffing capacity for the large and unpredictable referral volume View source Failure to prioritise referrals within urgency categories View source Lack of review of referral urgency categorisation View source Failure to ensure staff training and adherence to written Operational Guidance View source Failure of team management to coordinate and allocate referral-handling resources View source Failure to ensure that referral categorisation and allocation are performed by qualified and trained staff 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.
×
AI-generated summary
Howard Simon Sankey · 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
Howard Simon Sankey died on 4 July 2013 after being found suspended by a ligature in a garage, having left a note indicating his intention to end his life. The report raised concerns about the handling of his mental-health referral, including inappropriate categorisation, inadequate prioritisation and follow-up after failed contact, ineffective handovers and review systems, staffing levels, team management, and staff training.
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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of the computerised referral list to Senior Nurse Practitioners
Wider context from the report “(1) During the Inquest evidence was heard that :-
i) The categorisation and allocation as between Emergency, Urgent and Routine referrals is done by an Administration Assistant who is not qualified nor trained to carry out such duties. The Administration Assistant enters the service user on to the OTTER system with the category of urgency and the hard copy file is delivered to the Senior Nurse Practitioner including details of the referral which should be acknowledged by the Senior Nurse Practitioner within 30 minutes of receipt.
ii) There is no review of the hard copy file, the referral form or the entry on the electronic patient record to enable a review of the category of urgency assessed by the Administration Assistant. Furthermore there is no action taken by the Senior Nurse Practitioner to prioritise referrals within each category to identify the more urgent cases within each category to ensure contact with the service user within the most appropriate time for that service user.
iii) The OTTER system provides a list of all referrals in date and time order identifying the category of urgency but the list is not available to each Senior Nurse Practitioner and the list is only available to the Manager of the team.
iv) At the time of the referral relating to the deceased only one Senior Nurse Practitioner was on duty at any one time dealing with all referrals. The Gateway Team has 16 members who are engaged in different duties and many of the duties are out of the office. The Senior Nurse Practitioner on duty deals with all written or faxed referrals, including Emergency, Urgent and Routine referrals together with all telephone referrals and other request to Gateway either by telephone or by personal attendance. There are 500 to 600 recorded referrals to Gateway each month so that there are 25 to 30 referrals each working day.
Evidence was given at the Inquest that a new team has been established at the Hospital to deal with referrals through the Accident and Emergency Department at the Hospital and an additional member of staff now works with the Senior Nurse Practitioner in relation to other referrals but there is still a very high and unpredictable workload for the Senior Nurse Practitioner each day.
v) When a service user is not contacted or when an attempt to contact has failed the hard copy file is put into a file tray to be picked up whenever by another Senior Nurse Practitioner. There is no system of reviewing the none contact referrals within an appropriate and reasonable time. There is a handover from one Senior Nurse Practitioner to another Senior Nurse Practitioner at the end of each shift and there is a meeting each morning to discuss outstanding cases but there is no system to ensure that all outstanding cases are considered at the morning meeting and there is no re-prioritisation of the cases to ensure that all service users are contacted within an appropriate and reasonable period. In the case of the deceased his referral was not discussed at the morning meeting on the 3rd July 2013 after contact had failed at 19.36 hours the previous evening and his referral had not been reviewed by any Practitioner prior to his telephone call at 16.00 hours on the 3rd July 2013.
vi) The evidence at the Inquest revealed ineffective management of the Team to co-ordinate and allocate resources to deal with an unpredictable number of referrals each day. The list of referrals in date and time order prepared by the computer system is only accessible to the Team Manager who did not appear to share the information on the list with Senior Nurse Practitioners to ensure that any delays in contact with a service user would be actioned and reviewed taking account of the date and time of the referral.
2. I have concerns with regard to the 5 Boroughs Partnership NHS Foundation Trust, particularly the Gateway Team, in relation to:
i) The categorisation and allocation of referrals by an Administration Assistant who has insufficient knowledge and who is not trained to make such important decisions
ii) The prioritisation of each referral to ensure contact within an appropriate and reasonable period of time having regard to the urgency and merits of each referral.
iii) The system to ensure contact with service users within appropriate time periods particularly when the initial contact with the service user has failed.
iv) The systems and procedures to ensure contact with service users within appropriate time periods following receipt of the referral and the fact that the computerised list of referrals in date and time order is not available to Senior Nurse Practitioners.
v) The ineffectiveness of handovers as between Senior Nurse Practitioners and the ineffectiveness of the morning meetings to review referrals particularly those referrals where the initial contact with the service user has failed.
vi) The staffing levels on each shift, particularly having regard to a large and unpredictable volume of referrals each day.
vii) The ineffective management of the team as a whole and in particular Senior Nurse Practitioners to co-ordinate and allocate resources to deal with the large volume of referrals within the appropriate time period.
viii) The training of staff in relation to the written Operational Guidance, which was not followed by any of the Senior Nurse Practitioners who gave evidence at the Inquest, to ensure that referrals are dealt with and service users are seen within appropriate time periods.
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of handover and review systems to manage failed-contact referrals
Wider context from the report “(1) During the Inquest evidence was heard that :-
i) The categorisation and allocation as between Emergency, Urgent and Routine referrals is done by an Administration Assistant who is not qualified nor trained to carry out such duties. The Administration Assistant enters the service user on to the OTTER system with the category of urgency and the hard copy file is delivered to the Senior Nurse Practitioner including details of the referral which should be acknowledged by the Senior Nurse Practitioner within 30 minutes of receipt.
ii) There is no review of the hard copy file, the referral form or the entry on the electronic patient record to enable a review of the category of urgency assessed by the Administration Assistant. Furthermore there is no action taken by the Senior Nurse Practitioner to prioritise referrals within each category to identify the more urgent cases within each category to ensure contact with the service user within the most appropriate time for that service user.
iii) The OTTER system provides a list of all referrals in date and time order identifying the category of urgency but the list is not available to each Senior Nurse Practitioner and the list is only available to the Manager of the team.
iv) At the time of the referral relating to the deceased only one Senior Nurse Practitioner was on duty at any one time dealing with all referrals. The Gateway Team has 16 members who are engaged in different duties and many of the duties are out of the office. The Senior Nurse Practitioner on duty deals with all written or faxed referrals, including Emergency, Urgent and Routine referrals together with all telephone referrals and other request to Gateway either by telephone or by personal attendance. There are 500 to 600 recorded referrals to Gateway each month so that there are 25 to 30 referrals each working day.
Evidence was given at the Inquest that a new team has been established at the Hospital to deal with referrals through the Accident and Emergency Department at the Hospital and an additional member of staff now works with the Senior Nurse Practitioner in relation to other referrals but there is still a very high and unpredictable workload for the Senior Nurse Practitioner each day.
v) When a service user is not contacted or when an attempt to contact has failed the hard copy file is put into a file tray to be picked up whenever by another Senior Nurse Practitioner. There is no system of reviewing the none contact referrals within an appropriate and reasonable time. There is a handover from one Senior Nurse Practitioner to another Senior Nurse Practitioner at the end of each shift and there is a meeting each morning to discuss outstanding cases but there is no system to ensure that all outstanding cases are considered at the morning meeting and there is no re-prioritisation of the cases to ensure that all service users are contacted within an appropriate and reasonable period. In the case of the deceased his referral was not discussed at the morning meeting on the 3rd July 2013 after contact had failed at 19.36 hours the previous evening and his referral had not been reviewed by any Practitioner prior to his telephone call at 16.00 hours on the 3rd July 2013.
vi) The evidence at the Inquest revealed ineffective management of the Team to co-ordinate and allocate resources to deal with an unpredictable number of referrals each day. The list of referrals in date and time order prepared by the computer system is only accessible to the Team Manager who did not appear to share the information on the list with Senior Nurse Practitioners to ensure that any delays in contact with a service user would be actioned and reviewed taking account of the date and time of the referral.
2. I have concerns with regard to the 5 Boroughs Partnership NHS Foundation Trust, particularly the Gateway Team, in relation to:
i) The categorisation and allocation of referrals by an Administration Assistant who has insufficient knowledge and who is not trained to make such important decisions
ii) The prioritisation of each referral to ensure contact within an appropriate and reasonable period of time having regard to the urgency and merits of each referral.
iii) The system to ensure contact with service users within appropriate time periods particularly when the initial contact with the service user has failed.
iv) The systems and procedures to ensure contact with service users within appropriate time periods following receipt of the referral and the fact that the computerised list of referrals in date and time order is not available to Senior Nurse Practitioners.
v) The ineffectiveness of handovers as between Senior Nurse Practitioners and the ineffectiveness of the morning meetings to review referrals particularly those referrals where the initial contact with the service user has failed.
vi) The staffing levels on each shift, particularly having regard to a large and unpredictable volume of referrals each day.
vii) The ineffective management of the team as a whole and in particular Senior Nurse Practitioners to co-ordinate and allocate resources to deal with the large volume of referrals within the appropriate time period.
viii) The training of staff in relation to the written Operational Guidance, which was not followed by any of the Senior Nurse Practitioners who gave evidence at the Inquest, to ensure that referrals are dealt with and service users are seen within appropriate time periods.
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing capacity for the large and unpredictable referral volume
Wider context from the report “(1) During the Inquest evidence was heard that :-
i) The categorisation and allocation as between Emergency, Urgent and Routine referrals is done by an Administration Assistant who is not qualified nor trained to carry out such duties. The Administration Assistant enters the service user on to the OTTER system with the category of urgency and the hard copy file is delivered to the Senior Nurse Practitioner including details of the referral which should be acknowledged by the Senior Nurse Practitioner within 30 minutes of receipt.
ii) There is no review of the hard copy file, the referral form or the entry on the electronic patient record to enable a review of the category of urgency assessed by the Administration Assistant. Furthermore there is no action taken by the Senior Nurse Practitioner to prioritise referrals within each category to identify the more urgent cases within each category to ensure contact with the service user within the most appropriate time for that service user.
iii) The OTTER system provides a list of all referrals in date and time order identifying the category of urgency but the list is not available to each Senior Nurse Practitioner and the list is only available to the Manager of the team.
iv) At the time of the referral relating to the deceased only one Senior Nurse Practitioner was on duty at any one time dealing with all referrals. The Gateway Team has 16 members who are engaged in different duties and many of the duties are out of the office. The Senior Nurse Practitioner on duty deals with all written or faxed referrals, including Emergency, Urgent and Routine referrals together with all telephone referrals and other request to Gateway either by telephone or by personal attendance. There are 500 to 600 recorded referrals to Gateway each month so that there are 25 to 30 referrals each working day.
Evidence was given at the Inquest that a new team has been established at the Hospital to deal with referrals through the Accident and Emergency Department at the Hospital and an additional member of staff now works with the Senior Nurse Practitioner in relation to other referrals but there is still a very high and unpredictable workload for the Senior Nurse Practitioner each day.
v) When a service user is not contacted or when an attempt to contact has failed the hard copy file is put into a file tray to be picked up whenever by another Senior Nurse Practitioner. There is no system of reviewing the none contact referrals within an appropriate and reasonable time. There is a handover from one Senior Nurse Practitioner to another Senior Nurse Practitioner at the end of each shift and there is a meeting each morning to discuss outstanding cases but there is no system to ensure that all outstanding cases are considered at the morning meeting and there is no re-prioritisation of the cases to ensure that all service users are contacted within an appropriate and reasonable period. In the case of the deceased his referral was not discussed at the morning meeting on the 3rd July 2013 after contact had failed at 19.36 hours the previous evening and his referral had not been reviewed by any Practitioner prior to his telephone call at 16.00 hours on the 3rd July 2013.
vi) The evidence at the Inquest revealed ineffective management of the Team to co-ordinate and allocate resources to deal with an unpredictable number of referrals each day. The list of referrals in date and time order prepared by the computer system is only accessible to the Team Manager who did not appear to share the information on the list with Senior Nurse Practitioners to ensure that any delays in contact with a service user would be actioned and reviewed taking account of the date and time of the referral.
2. I have concerns with regard to the 5 Boroughs Partnership NHS Foundation Trust, particularly the Gateway Team, in relation to:
i) The categorisation and allocation of referrals by an Administration Assistant who has insufficient knowledge and who is not trained to make such important decisions
ii) The prioritisation of each referral to ensure contact within an appropriate and reasonable period of time having regard to the urgency and merits of each referral.
iii) The system to ensure contact with service users within appropriate time periods particularly when the initial contact with the service user has failed.
iv) The systems and procedures to ensure contact with service users within appropriate time periods following receipt of the referral and the fact that the computerised list of referrals in date and time order is not available to Senior Nurse Practitioners.
v) The ineffectiveness of handovers as between Senior Nurse Practitioners and the ineffectiveness of the morning meetings to review referrals particularly those referrals where the initial contact with the service user has failed.
vi) The staffing levels on each shift, particularly having regard to a large and unpredictable volume of referrals each day.
vii) The ineffective management of the team as a whole and in particular Senior Nurse Practitioners to co-ordinate and allocate resources to deal with the large volume of referrals within the appropriate time period.
viii) The training of staff in relation to the written Operational Guidance, which was not followed by any of the Senior Nurse Practitioners who gave evidence at the Inquest, to ensure that referrals are dealt with and service users are seen within appropriate time periods.
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise referrals within urgency categories
Wider context from the report “(1) During the Inquest evidence was heard that :-
i) The categorisation and allocation as between Emergency, Urgent and Routine referrals is done by an Administration Assistant who is not qualified nor trained to carry out such duties. The Administration Assistant enters the service user on to the OTTER system with the category of urgency and the hard copy file is delivered to the Senior Nurse Practitioner including details of the referral which should be acknowledged by the Senior Nurse Practitioner within 30 minutes of receipt.
ii) There is no review of the hard copy file, the referral form or the entry on the electronic patient record to enable a review of the category of urgency assessed by the Administration Assistant. Furthermore there is no action taken by the Senior Nurse Practitioner to prioritise referrals within each category to identify the more urgent cases within each category to ensure contact with the service user within the most appropriate time for that service user.
iii) The OTTER system provides a list of all referrals in date and time order identifying the category of urgency but the list is not available to each Senior Nurse Practitioner and the list is only available to the Manager of the team.
iv) At the time of the referral relating to the deceased only one Senior Nurse Practitioner was on duty at any one time dealing with all referrals. The Gateway Team has 16 members who are engaged in different duties and many of the duties are out of the office. The Senior Nurse Practitioner on duty deals with all written or faxed referrals, including Emergency, Urgent and Routine referrals together with all telephone referrals and other request to Gateway either by telephone or by personal attendance. There are 500 to 600 recorded referrals to Gateway each month so that there are 25 to 30 referrals each working day.
Evidence was given at the Inquest that a new team has been established at the Hospital to deal with referrals through the Accident and Emergency Department at the Hospital and an additional member of staff now works with the Senior Nurse Practitioner in relation to other referrals but there is still a very high and unpredictable workload for the Senior Nurse Practitioner each day.
v) When a service user is not contacted or when an attempt to contact has failed the hard copy file is put into a file tray to be picked up whenever by another Senior Nurse Practitioner. There is no system of reviewing the none contact referrals within an appropriate and reasonable time. There is a handover from one Senior Nurse Practitioner to another Senior Nurse Practitioner at the end of each shift and there is a meeting each morning to discuss outstanding cases but there is no system to ensure that all outstanding cases are considered at the morning meeting and there is no re-prioritisation of the cases to ensure that all service users are contacted within an appropriate and reasonable period. In the case of the deceased his referral was not discussed at the morning meeting on the 3rd July 2013 after contact had failed at 19.36 hours the previous evening and his referral had not been reviewed by any Practitioner prior to his telephone call at 16.00 hours on the 3rd July 2013.
vi) The evidence at the Inquest revealed ineffective management of the Team to co-ordinate and allocate resources to deal with an unpredictable number of referrals each day. The list of referrals in date and time order prepared by the computer system is only accessible to the Team Manager who did not appear to share the information on the list with Senior Nurse Practitioners to ensure that any delays in contact with a service user would be actioned and reviewed taking account of the date and time of the referral.
2. I have concerns with regard to the 5 Boroughs Partnership NHS Foundation Trust, particularly the Gateway Team, in relation to:
i) The categorisation and allocation of referrals by an Administration Assistant who has insufficient knowledge and who is not trained to make such important decisions
ii) The prioritisation of each referral to ensure contact within an appropriate and reasonable period of time having regard to the urgency and merits of each referral.
iii) The system to ensure contact with service users within appropriate time periods particularly when the initial contact with the service user has failed.
iv) The systems and procedures to ensure contact with service users within appropriate time periods following receipt of the referral and the fact that the computerised list of referrals in date and time order is not available to Senior Nurse Practitioners.
v) The ineffectiveness of handovers as between Senior Nurse Practitioners and the ineffectiveness of the morning meetings to review referrals particularly those referrals where the initial contact with the service user has failed.
vi) The staffing levels on each shift, particularly having regard to a large and unpredictable volume of referrals each day.
vii) The ineffective management of the team as a whole and in particular Senior Nurse Practitioners to co-ordinate and allocate resources to deal with the large volume of referrals within the appropriate time period.
viii) The training of staff in relation to the written Operational Guidance, which was not followed by any of the Senior Nurse Practitioners who gave evidence at the Inquest, to ensure that referrals are dealt with and service users are seen within appropriate time periods.
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of review of referral urgency categorisation
Wider context from the report “(1) During the Inquest evidence was heard that :-
i) The categorisation and allocation as between Emergency, Urgent and Routine referrals is done by an Administration Assistant who is not qualified nor trained to carry out such duties. The Administration Assistant enters the service user on to the OTTER system with the category of urgency and the hard copy file is delivered to the Senior Nurse Practitioner including details of the referral which should be acknowledged by the Senior Nurse Practitioner within 30 minutes of receipt.
ii) There is no review of the hard copy file, the referral form or the entry on the electronic patient record to enable a review of the category of urgency assessed by the Administration Assistant. Furthermore there is no action taken by the Senior Nurse Practitioner to prioritise referrals within each category to identify the more urgent cases within each category to ensure contact with the service user within the most appropriate time for that service user.
iii) The OTTER system provides a list of all referrals in date and time order identifying the category of urgency but the list is not available to each Senior Nurse Practitioner and the list is only available to the Manager of the team.
iv) At the time of the referral relating to the deceased only one Senior Nurse Practitioner was on duty at any one time dealing with all referrals. The Gateway Team has 16 members who are engaged in different duties and many of the duties are out of the office. The Senior Nurse Practitioner on duty deals with all written or faxed referrals, including Emergency, Urgent and Routine referrals together with all telephone referrals and other request to Gateway either by telephone or by personal attendance. There are 500 to 600 recorded referrals to Gateway each month so that there are 25 to 30 referrals each working day.
Evidence was given at the Inquest that a new team has been established at the Hospital to deal with referrals through the Accident and Emergency Department at the Hospital and an additional member of staff now works with the Senior Nurse Practitioner in relation to other referrals but there is still a very high and unpredictable workload for the Senior Nurse Practitioner each day.
v) When a service user is not contacted or when an attempt to contact has failed the hard copy file is put into a file tray to be picked up whenever by another Senior Nurse Practitioner. There is no system of reviewing the none contact referrals within an appropriate and reasonable time. There is a handover from one Senior Nurse Practitioner to another Senior Nurse Practitioner at the end of each shift and there is a meeting each morning to discuss outstanding cases but there is no system to ensure that all outstanding cases are considered at the morning meeting and there is no re-prioritisation of the cases to ensure that all service users are contacted within an appropriate and reasonable period. In the case of the deceased his referral was not discussed at the morning meeting on the 3rd July 2013 after contact had failed at 19.36 hours the previous evening and his referral had not been reviewed by any Practitioner prior to his telephone call at 16.00 hours on the 3rd July 2013.
vi) The evidence at the Inquest revealed ineffective management of the Team to co-ordinate and allocate resources to deal with an unpredictable number of referrals each day. The list of referrals in date and time order prepared by the computer system is only accessible to the Team Manager who did not appear to share the information on the list with Senior Nurse Practitioners to ensure that any delays in contact with a service user would be actioned and reviewed taking account of the date and time of the referral.
2. I have concerns with regard to the 5 Boroughs Partnership NHS Foundation Trust, particularly the Gateway Team, in relation to:
i) The categorisation and allocation of referrals by an Administration Assistant who has insufficient knowledge and who is not trained to make such important decisions
ii) The prioritisation of each referral to ensure contact within an appropriate and reasonable period of time having regard to the urgency and merits of each referral.
iii) The system to ensure contact with service users within appropriate time periods particularly when the initial contact with the service user has failed.
iv) The systems and procedures to ensure contact with service users within appropriate time periods following receipt of the referral and the fact that the computerised list of referrals in date and time order is not available to Senior Nurse Practitioners.
v) The ineffectiveness of handovers as between Senior Nurse Practitioners and the ineffectiveness of the morning meetings to review referrals particularly those referrals where the initial contact with the service user has failed.
vi) The staffing levels on each shift, particularly having regard to a large and unpredictable volume of referrals each day.
vii) The ineffective management of the team as a whole and in particular Senior Nurse Practitioners to co-ordinate and allocate resources to deal with the large volume of referrals within the appropriate time period.
viii) The training of staff in relation to the written Operational Guidance, which was not followed by any of the Senior Nurse Practitioners who gave evidence at the Inquest, to ensure that referrals are dealt with and service users are seen within appropriate time periods.
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff training and adherence to written Operational Guidance
Wider context from the report “(1) During the Inquest evidence was heard that :-
i) The categorisation and allocation as between Emergency, Urgent and Routine referrals is done by an Administration Assistant who is not qualified nor trained to carry out such duties. The Administration Assistant enters the service user on to the OTTER system with the category of urgency and the hard copy file is delivered to the Senior Nurse Practitioner including details of the referral which should be acknowledged by the Senior Nurse Practitioner within 30 minutes of receipt.
ii) There is no review of the hard copy file, the referral form or the entry on the electronic patient record to enable a review of the category of urgency assessed by the Administration Assistant. Furthermore there is no action taken by the Senior Nurse Practitioner to prioritise referrals within each category to identify the more urgent cases within each category to ensure contact with the service user within the most appropriate time for that service user.
iii) The OTTER system provides a list of all referrals in date and time order identifying the category of urgency but the list is not available to each Senior Nurse Practitioner and the list is only available to the Manager of the team.
iv) At the time of the referral relating to the deceased only one Senior Nurse Practitioner was on duty at any one time dealing with all referrals. The Gateway Team has 16 members who are engaged in different duties and many of the duties are out of the office. The Senior Nurse Practitioner on duty deals with all written or faxed referrals, including Emergency, Urgent and Routine referrals together with all telephone referrals and other request to Gateway either by telephone or by personal attendance. There are 500 to 600 recorded referrals to Gateway each month so that there are 25 to 30 referrals each working day.
Evidence was given at the Inquest that a new team has been established at the Hospital to deal with referrals through the Accident and Emergency Department at the Hospital and an additional member of staff now works with the Senior Nurse Practitioner in relation to other referrals but there is still a very high and unpredictable workload for the Senior Nurse Practitioner each day.
v) When a service user is not contacted or when an attempt to contact has failed the hard copy file is put into a file tray to be picked up whenever by another Senior Nurse Practitioner. There is no system of reviewing the none contact referrals within an appropriate and reasonable time. There is a handover from one Senior Nurse Practitioner to another Senior Nurse Practitioner at the end of each shift and there is a meeting each morning to discuss outstanding cases but there is no system to ensure that all outstanding cases are considered at the morning meeting and there is no re-prioritisation of the cases to ensure that all service users are contacted within an appropriate and reasonable period. In the case of the deceased his referral was not discussed at the morning meeting on the 3rd July 2013 after contact had failed at 19.36 hours the previous evening and his referral had not been reviewed by any Practitioner prior to his telephone call at 16.00 hours on the 3rd July 2013.
vi) The evidence at the Inquest revealed ineffective management of the Team to co-ordinate and allocate resources to deal with an unpredictable number of referrals each day. The list of referrals in date and time order prepared by the computer system is only accessible to the Team Manager who did not appear to share the information on the list with Senior Nurse Practitioners to ensure that any delays in contact with a service user would be actioned and reviewed taking account of the date and time of the referral.
2. I have concerns with regard to the 5 Boroughs Partnership NHS Foundation Trust, particularly the Gateway Team, in relation to:
i) The categorisation and allocation of referrals by an Administration Assistant who has insufficient knowledge and who is not trained to make such important decisions
ii) The prioritisation of each referral to ensure contact within an appropriate and reasonable period of time having regard to the urgency and merits of each referral.
iii) The system to ensure contact with service users within appropriate time periods particularly when the initial contact with the service user has failed.
iv) The systems and procedures to ensure contact with service users within appropriate time periods following receipt of the referral and the fact that the computerised list of referrals in date and time order is not available to Senior Nurse Practitioners.
v) The ineffectiveness of handovers as between Senior Nurse Practitioners and the ineffectiveness of the morning meetings to review referrals particularly those referrals where the initial contact with the service user has failed.
vi) The staffing levels on each shift, particularly having regard to a large and unpredictable volume of referrals each day.
vii) The ineffective management of the team as a whole and in particular Senior Nurse Practitioners to co-ordinate and allocate resources to deal with the large volume of referrals within the appropriate time period.
viii) The training of staff in relation to the written Operational Guidance, which was not followed by any of the Senior Nurse Practitioners who gave evidence at the Inquest, to ensure that referrals are dealt with and service users are seen within appropriate time periods.
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of team management to coordinate and allocate referral-handling resources
Wider context from the report “(1) During the Inquest evidence was heard that :-
i) The categorisation and allocation as between Emergency, Urgent and Routine referrals is done by an Administration Assistant who is not qualified nor trained to carry out such duties. The Administration Assistant enters the service user on to the OTTER system with the category of urgency and the hard copy file is delivered to the Senior Nurse Practitioner including details of the referral which should be acknowledged by the Senior Nurse Practitioner within 30 minutes of receipt.
ii) There is no review of the hard copy file, the referral form or the entry on the electronic patient record to enable a review of the category of urgency assessed by the Administration Assistant. Furthermore there is no action taken by the Senior Nurse Practitioner to prioritise referrals within each category to identify the more urgent cases within each category to ensure contact with the service user within the most appropriate time for that service user.
iii) The OTTER system provides a list of all referrals in date and time order identifying the category of urgency but the list is not available to each Senior Nurse Practitioner and the list is only available to the Manager of the team.
iv) At the time of the referral relating to the deceased only one Senior Nurse Practitioner was on duty at any one time dealing with all referrals. The Gateway Team has 16 members who are engaged in different duties and many of the duties are out of the office. The Senior Nurse Practitioner on duty deals with all written or faxed referrals, including Emergency, Urgent and Routine referrals together with all telephone referrals and other request to Gateway either by telephone or by personal attendance. There are 500 to 600 recorded referrals to Gateway each month so that there are 25 to 30 referrals each working day.
Evidence was given at the Inquest that a new team has been established at the Hospital to deal with referrals through the Accident and Emergency Department at the Hospital and an additional member of staff now works with the Senior Nurse Practitioner in relation to other referrals but there is still a very high and unpredictable workload for the Senior Nurse Practitioner each day.
v) When a service user is not contacted or when an attempt to contact has failed the hard copy file is put into a file tray to be picked up whenever by another Senior Nurse Practitioner. There is no system of reviewing the none contact referrals within an appropriate and reasonable time. There is a handover from one Senior Nurse Practitioner to another Senior Nurse Practitioner at the end of each shift and there is a meeting each morning to discuss outstanding cases but there is no system to ensure that all outstanding cases are considered at the morning meeting and there is no re-prioritisation of the cases to ensure that all service users are contacted within an appropriate and reasonable period. In the case of the deceased his referral was not discussed at the morning meeting on the 3rd July 2013 after contact had failed at 19.36 hours the previous evening and his referral had not been reviewed by any Practitioner prior to his telephone call at 16.00 hours on the 3rd July 2013.
vi) The evidence at the Inquest revealed ineffective management of the Team to co-ordinate and allocate resources to deal with an unpredictable number of referrals each day. The list of referrals in date and time order prepared by the computer system is only accessible to the Team Manager who did not appear to share the information on the list with Senior Nurse Practitioners to ensure that any delays in contact with a service user would be actioned and reviewed taking account of the date and time of the referral.
2. I have concerns with regard to the 5 Boroughs Partnership NHS Foundation Trust, particularly the Gateway Team, in relation to:
i) The categorisation and allocation of referrals by an Administration Assistant who has insufficient knowledge and who is not trained to make such important decisions
ii) The prioritisation of each referral to ensure contact within an appropriate and reasonable period of time having regard to the urgency and merits of each referral.
iii) The system to ensure contact with service users within appropriate time periods particularly when the initial contact with the service user has failed.
iv) The systems and procedures to ensure contact with service users within appropriate time periods following receipt of the referral and the fact that the computerised list of referrals in date and time order is not available to Senior Nurse Practitioners.
v) The ineffectiveness of handovers as between Senior Nurse Practitioners and the ineffectiveness of the morning meetings to review referrals particularly those referrals where the initial contact with the service user has failed.
vi) The staffing levels on each shift, particularly having regard to a large and unpredictable volume of referrals each day.
vii) The ineffective management of the team as a whole and in particular Senior Nurse Practitioners to co-ordinate and allocate resources to deal with the large volume of referrals within the appropriate time period.
viii) The training of staff in relation to the written Operational Guidance, which was not followed by any of the Senior Nurse Practitioners who gave evidence at the Inquest, to ensure that referrals are dealt with and service users are seen within appropriate time periods.
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that referral categorisation and allocation are performed by qualified and trained staff
Wider context from the report “(1) During the Inquest evidence was heard that :-
i) The categorisation and allocation as between Emergency, Urgent and Routine referrals is done by an Administration Assistant who is not qualified nor trained to carry out such duties. The Administration Assistant enters the service user on to the OTTER system with the category of urgency and the hard copy file is delivered to the Senior Nurse Practitioner including details of the referral which should be acknowledged by the Senior Nurse Practitioner within 30 minutes of receipt.
ii) There is no review of the hard copy file, the referral form or the entry on the electronic patient record to enable a review of the category of urgency assessed by the Administration Assistant. Furthermore there is no action taken by the Senior Nurse Practitioner to prioritise referrals within each category to identify the more urgent cases within each category to ensure contact with the service user within the most appropriate time for that service user.
iii) The OTTER system provides a list of all referrals in date and time order identifying the category of urgency but the list is not available to each Senior Nurse Practitioner and the list is only available to the Manager of the team.
iv) At the time of the referral relating to the deceased only one Senior Nurse Practitioner was on duty at any one time dealing with all referrals. The Gateway Team has 16 members who are engaged in different duties and many of the duties are out of the office. The Senior Nurse Practitioner on duty deals with all written or faxed referrals, including Emergency, Urgent and Routine referrals together with all telephone referrals and other request to Gateway either by telephone or by personal attendance. There are 500 to 600 recorded referrals to Gateway each month so that there are 25 to 30 referrals each working day.
Evidence was given at the Inquest that a new team has been established at the Hospital to deal with referrals through the Accident and Emergency Department at the Hospital and an additional member of staff now works with the Senior Nurse Practitioner in relation to other referrals but there is still a very high and unpredictable workload for the Senior Nurse Practitioner each day.
v) When a service user is not contacted or when an attempt to contact has failed the hard copy file is put into a file tray to be picked up whenever by another Senior Nurse Practitioner. There is no system of reviewing the none contact referrals within an appropriate and reasonable time. There is a handover from one Senior Nurse Practitioner to another Senior Nurse Practitioner at the end of each shift and there is a meeting each morning to discuss outstanding cases but there is no system to ensure that all outstanding cases are considered at the morning meeting and there is no re-prioritisation of the cases to ensure that all service users are contacted within an appropriate and reasonable period. In the case of the deceased his referral was not discussed at the morning meeting on the 3rd July 2013 after contact had failed at 19.36 hours the previous evening and his referral had not been reviewed by any Practitioner prior to his telephone call at 16.00 hours on the 3rd July 2013.
vi) The evidence at the Inquest revealed ineffective management of the Team to co-ordinate and allocate resources to deal with an unpredictable number of referrals each day. The list of referrals in date and time order prepared by the computer system is only accessible to the Team Manager who did not appear to share the information on the list with Senior Nurse Practitioners to ensure that any delays in contact with a service user would be actioned and reviewed taking account of the date and time of the referral.
2. I have concerns with regard to the 5 Boroughs Partnership NHS Foundation Trust, particularly the Gateway Team, in relation to:
i) The categorisation and allocation of referrals by an Administration Assistant who has insufficient knowledge and who is not trained to make such important decisions
ii) The prioritisation of each referral to ensure contact within an appropriate and reasonable period of time having regard to the urgency and merits of each referral.
iii) The system to ensure contact with service users within appropriate time periods particularly when the initial contact with the service user has failed.
iv) The systems and procedures to ensure contact with service users within appropriate time periods following receipt of the referral and the fact that the computerised list of referrals in date and time order is not available to Senior Nurse Practitioners.
v) The ineffectiveness of handovers as between Senior Nurse Practitioners and the ineffectiveness of the morning meetings to review referrals particularly those referrals where the initial contact with the service user has failed.
vi) The staffing levels on each shift, particularly having regard to a large and unpredictable volume of referrals each day.
vii) The ineffective management of the team as a whole and in particular Senior Nurse Practitioners to co-ordinate and allocate resources to deal with the large volume of referrals within the appropriate time period.
viii) The training of staff in relation to the written Operational Guidance, which was not followed by any of the Senior Nurse Practitioners who gave evidence at the Inquest, to ensure that referrals are dealt with and service users are seen within appropriate time periods.
” Open source report
14 Oct 2013 Yousef SHOKRI-GHARAB · Prevention of Future Deaths report Liverpool
View report summary
Concerns raised 2 Failure to review and update the informal-patient leave policy View source Failure to document informal-patient leave start and expected return times before leave View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Yousef SHOKRI-GHARAB · 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
Yousef SHOKRI-GHARAB, an asylum seeker receiving inpatient treatment for mental illness, was found collapsed in a disused car park on 20 June 2013 and died at the Royal Liverpool University Hospital after attempts at resuscitation. The inquest concluded that he died from morphine (heroin) toxicity. Concerns included an outdated Mersey Care policy on leave for informal patients, which did not reflect practice, and leave permissions being authorised without regard to the Responsible Medical Officer's opinion.
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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review and update the informal-patient leave policy
Wider context from the report “The Mersey Care Policy and Procedure for leave for an informal patient was ratified in October 2006 and was due for review in October 2007. It has not been reviewed. The policy does not reflect practice. The policy needs to be updated immediately to protect patients and to be fair to employees of Mersey Care. To reflect current practice the policy should reflect amongst other matters that leave is permitted when observations are reduced to level 1 and there has been a multidisciplinary team consensus that a regime of leave is appropriate having consideration to (i) the deceased's vulnerability, (ii) the fact that the hospital had assumed responsibility for the patient's welfare and safety, including by the exercise of control, and (iii) the nature of the risk and whether it was "exceptional" rather than "ordinary"
The policy should include stressing the importance of documenting before leave the time of taking leave and when the patient is due back. The operation of the policy should be audited to ensure compliance.
” 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 Mersey Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document informal-patient leave start and expected return times before leave
Wider context from the report “The Mersey Care Policy and Procedure for leave for an informal patient was ratified in October 2006 and was due for review in October 2007. It has not been reviewed. The policy does not reflect practice. The policy needs to be updated immediately to protect patients and to be fair to employees of Mersey Care. To reflect current practice the policy should reflect amongst other matters that leave is permitted when observations are reduced to level 1 and there has been a multidisciplinary team consensus that a regime of leave is appropriate having consideration to (i) the deceased's vulnerability, (ii) the fact that the hospital had assumed responsibility for the patient's welfare and safety, including by the exercise of control, and (iii) the nature of the risk and whether it was "exceptional" rather than "ordinary"
The policy should include stressing the importance of documenting before leave the time of taking leave and when the patient is due back. The operation of the policy should be audited to ensure compliance.
” 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 Review and update Trust policies so they reflect national best practice.
Verbatim wording from the response “I can confirm that the Corporate Governance Team have been tasked with ensuring that all policies are received and updated to ensure that they reflect national best practice. Of the 120 Corporate Policies and Procedures currently in place, 117 are now in date. Three policies are subject to a fundamental review; this process will be completed by 31st March 2014. Between November 2013 and 12th February 2014, 50 policies have been reviewed and updated.” Source location 2013-0259-Response-by-Mersey-Care-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 Review and update the policy identified as a concern at the inquest.
Verbatim wording from the response “I can confirm that the policy that provided you with concern at the Inquest on 11th October 2013 was one of the first to be reviewed and updated.” Source location 2013-0259-Response-by-Mersey-Care-NHS
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 Complete the fundamental reviews of the three remaining out-of-date policies by 31 March 2014.
Verbatim wording from the response “I can confirm that the Corporate Governance Team have been tasked with ensuring that all policies are received and updated to ensure that they reflect national best practice. Of the 120 Corporate Policies and Procedures currently in place, 117 are now in date. Three policies are subject to a fundamental review; this process will be completed by 31st March 2014. Between November 2013 and 12th February 2014, 50 policies have been reviewed and updated.” Source location 2013-0259-Response-by-Mersey-Care-NHS
Open published response
Pin
Request correction
Addressed to North West Boroughs Healthcare NHS Foundation Trust, now represented here by Mersey Care NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations